Disrespect, Abuse, and Satisfaction With Facility‐Based Childbirth in Rural Bangladesh

ABSTRACT

Background and Aims

In rural Bangladesh, despite efforts to improve maternal healthcare, women still face mistreatment during childbirth, which can affect their satisfaction with care. This study aims to investigate the prevalence of disrespect and abuse (D&A) during facility‐based childbirth, explore its impact on women's satisfaction, and identify key factors that influence these experiences, to inform strategies for improving maternal care.

Methods

This facility‐based cross‐sectional study was conducted at four community clinics in rural Rajshahi, Bangladesh. The study included 400 women who gave birth in designated healthcare facilities and were preparing to leave for a postpartum room. D&A care was defined using six categories: physical abuse, non‐confidential care, non‐consented care, non‐dignified care, invasion of privacy, and abandonment. Maternal satisfaction outcomes included satisfaction with care received and willingness to recommend the facility to others.

Results

25.8% of women received D&A care. According to multivariate logistic regression analysis, mothers who gave birth at night or without the presence of birth companions, mothers who had a vaginal birth or did not receive four or more ANC visits, mothers in the poorest wealth bands, and mothers who had assisted births other than by medical professionals were more likely to report D&A care than their counterparts. There was a higher likelihood of satisfaction (adjusted odds ratio [AOR]: 3.35; 95% CI: 2.81 to 5.81) and of recommending the facility to others (AOR: 2.74; 95% CI: 1.95 to 4.23) among women who reported not having D&A experiences.

Conclusions

D&A care is highly prevalent in primary healthcare settings in rural Bangladesh. The significant contributing factors identified in this study should be addressed to reduce the occurrence of D&A care.

1. Introduction

Bangladesh has made significant progress in decreasing the maternal mortality ratio (MMR), which dropped from 550 per 100,000 live births in 1990 to 176 per 100,000 live births in 2015, as estimated. However, compared with many developing countries, this figure is still high [1]. To meet Sustainable Development Goal 3.1, which aims for an MMR of less than 70 per 100,000 live births by 2030, further efforts are essential [2]. From 1990 to 2015 [3], Bangladesh's average annual rate of MMR reduction was only 5%. Thus, accelerating progress in reducing maternal deaths must be prioritized to achieve the SDGs targets for MMR in the country.

Complications during pregnancy and childbirth are major contributors to maternal mortality and morbidity in Bangladesh [4] as in many other developing countries [5]. It is widely acknowledged that access to skilled childbirth services within an effective healthcare system can prevent many maternal deaths [6]. However, despite improvements in healthcare access, only 37% of women in Bangladesh give birth with skilled birth attendants at health institutions [7]. However, access to skilled care alone, though critical, is insufficient to guarantee maternal health outcomes; the quality of care provided is equally important [8]. Even where services are available, mistreatment during childbirth, such as abusive, neglectful, or disrespectful care, can compromise the care received [9, 10]. Care satisfaction [11] is another vital indicator of quality care and can be used to monitor and improve maternal health services. This issue is increasingly recognized in the post‐2015 development agenda, which emphasizes the need for quality in health service delivery [12].

In rural areas of Bangladesh, where recruiting and retaining qualified healthcare personnel is challenging, the shortcomings in service quality for pregnancy and childbirth care become more pronounced [13]. The low access to skilled childbirth services and the poor quality of maternity care in Bangladesh and other low socioeconomic settings are often attributed to factors such as lower education levels [14, 15], lack of awareness [16], high birth order [17], unemployment [17], inaccessibility of services [17], hidden treatment costs [18], remoteness [19], poor reception at health facilities [19], lack of privacy [19], unsympathetic staff [19], unavailability of skilled personnel [19], and poor economic conditions. However, psychosocial factors that influence women's low utilization of and satisfaction with maternity care have been less studied. One such factor is the disrespect and abuse (D&A) women face during facility‐based childbirth, which may further deter them from seeking care. Another contributing factor to low service utilization is dissatisfaction with care during childbirth.

D&A during childbirth refers to mistreatment, obstetric abuse, and dehumanizing care that women experience from healthcare providers. This can manifest as physical violence, rude language, stigma, and carelessness [20]. Satisfaction with healthcare services reflects how positively patients perceive the care they receive from medical or nursing staff [11]. D&A during childbirth and patient satisfaction have been studied widely qualitatively [9, 21], but there has been a substantial and growing body of quantitative research on this topic in recent years. Large‐scale surveys, prevalence studies, and systematic reviews have been conducted on the impact and the type of D&A pertaining to childbirth. For example, depending on Bohren et al.'s landmark mixed‐methods systematic review [10], more recent quantitative studies such as Limmer et al. have used their quantitative frameworks to try to develop and validate measurement instruments and found that 77% of women surveyed had experienced at least some form of mistreatment during delivery in Germany [22]. This indicates that D&A is a widespread issue not confined to low‐resource settings. While most of the existing studies concentrate on urban areas, there is limited research on the prevalence of D&A in rural settings. Specifically, there has been no research on the prevalence of D &A during childbirth in rural Bangladesh, and little data exists on mothers' satisfaction with the care they receive after childbirth. Our study, therefore, aims to add to this growing body of research by providing valuable local data from rural Bangladesh, a context that has been under‐researched.

In a global context over the last few years, D&A has turned out to be a major maternal health issue, framed along systemic, structural, and rights‐based dimensions. Based on this classification, Bowser and Hill have analyzed D&A into seven basic forms of misconceptions: physical abuse, non‐consented clinical care, non‐confidential care, non‐dignified care, discrimination, abandonment of care, and detention in facilities [23]. This emphasizes how mistreatment against women has many aspects in that it includes physical violence and emotional agony. Thus, the definition of D&A as a violation of women's human rights must include that treatment in pregnancy and childbirth be dignified, and it is an important aspect of quality maternal health services. These frameworks reflect that D&A involves much wider issues within health systems that resonate with societal inequalities and power imbalances deeply rooted. Understanding D&A as both a clinical and rights‐based issue is critical for addressing the root causes of mistreatment and improving maternal health outcomes. This conceptual lens strengthens the foundation of the current study, situating it within global discussions toward the improvement of quality and dignity in maternal care. The specific hypotheses for this study are as follows:

Hypothesis 1

Women are less likely to be satisfied with the care they receive who experience D&A during childbirth.

Hypothesis 2

Women who are dissatisfied with their care during childbirth are less likely to recommend the delivery facility to others.

This study aimed to ascertain the proportion of women who had received D&A care during a facility‐based delivery, as well as the impact this had on their satisfaction with care and their likelihood of recommending the same delivery facility to others. The specific goals of the study are (i) to determine the proportion of women who have experienced various types of D&A care during childbirth, and (ii) to investigate the factors that contribute to D&A care.

2. Methods

2.1. Design, Settings, and Study Population

This is an institution‐based cross‐sectional study. The participants were selected from four community clinics located in Bangladesh's rural Rajshahi district. Mothers who were ready to leave the postnatal room after giving birth at the selected study institutions were included.

2.2. Sampling Frame

This study was conducted in two Upazilas (sub‐districts), namely Mohanpur and Paba. The administrative divisions of Paba and Mohanpur Upazilas are Union Parishad (UP) and municipality. Paba has nine Ups, while Mohapur Upazila has eight [24]. There were 312,866 people living in Paba Upazila and 213,182 in Mohanpur Upazila, with 76,622 and 43,984 homes, respectively. In Paba, there are 36 public and eight private healthcare facilities; in Mohanpur Upazila, the corresponding numbers are 32 public and one private. Skilled health personnel attended 40.4% and 49.2% births in Paba and Mohanpur Upazila, respectively [24].

A multi‐stage random selection technique was used to choose drawing participants (Figure 1). Two Upazilas (sub‐districts) were chosen in the first stage from among the nine Upazilas in the Rajshahi district: Mohanpur and Paba. In the second stage, we randomly selected two unions from a total of eight UPS from Mohanpur and nine UPS from Paba. Of these two UPSs, four community clinics were randomly selected for the third stage. Four hundred mothers were selected in equal numbers from each of these four community clinics for the final phase.

Figure 1.

Participant selection process and exclusions for women from Rajshahi District.

Community clinics provide primary healthcare in Bangladesh [25]. The main services of these clinics are maternal and neonatal healthcare, nutrition and health education, and treatment of minor ailments. Community healthcare providers manage community clinics, supported by a family welfare assistant and a health assistant. Community healthcare providers and health assistants generally hold bachelor's or master's degrees, while most family welfare assistants have completed higher secondary education. Rajshahi was selected for this study because it has sufficient community clinics required for our study and is close to our research headquarters, the University of Rajshahi; therefore, regular visits by the research staff from the University of Rajshahi could be made easily.

2.3. Sampling Procedure

The study included women who gave birth at one of the selected community clinics in rural Rajshahi between December 1 and December 31, 2024, and who were ready to leave the facility and were placed in the postpartum room at the time of the survey. Only women who had uncomplicated deliveries were eligible for inclusion. Women were excluded from the study if they experienced complicated deliveries, such as postpartum hemorrhage or extensive perineal tears needing surgical repair, or if their babies had an Apgar score so low as to require special medical attention. In addition, women who had vacuum‐assisted births or emergency Cesarean (C)‐sections under general anesthesia were also excluded due to the potential influence of these procedures on women's perceptions of care. However, C‐sections performed with spinal or epidural anesthesia were included, as these types of anesthesia typically allow women to recall their childbirth experience and provide reliable data on their perceptions of D&A care. Women who delivered at home were also excluded from the study to avoid biases, as they might have avoided facility‐based care due to prior negative experiences, for example, mistreatment or dissatisfaction with care in health facilities.

To ensure that each qualified potential respondent in the sampling frame had an equal chance of being included in the study, the register of all women who gave birth at the facility between December 01 and 31, 2024, was obtained from the community clinics' registry book. A Google‐based random‐number generator was used to select the names of all women who had live, uncomplicated deliveries, using the previously mentioned inclusion and exclusion criteria. The required number of respondents was then randomly selected.

A single‐proportion formula was used to estimate the required sample size for the study. The sample size calculation assumed a 50% (p) estimated level of D&A‐free maternity care (since there is no D&A prevalence study in Bangladesh) and, with a 95% confidence level and a 5% margin of error, the minimum sample size was 384 mothers. The minimum sample size of 384 was further increased to 400 to cater for the possible non‐response rate (Figure 1).

2.4. Data Collection

This study was conducted using a structured questionnaire that generated data on D&A experienced during facility‐based childbirth and maternal satisfaction with care received. Data was collected using in‐person interviews. The survey collected socio‐demographic characteristics and obstetric history, D&A care experiences, and satisfaction with maternal care. The questionnaire was based on the Maternal and Child Health Integrated Program (MCHIP) reflective maternity care toolbox [26], which is a widely used tool in international maternal health research. This adaptation was required to freshen up the tool for use within the Bangladeshi context, as the questions needed to be relevant for maternity healthcare practices and cultural nuances.

2.5. Data Quality Assurance and Questionnaire Validation

First, the survey instrument was adapted from the MCHIP toolkit for respectful maternity care, and included items on physical abuse, non‐consented care, non‐dignified care or treatment without dignity, invasion of privacy, abandonment, among many others. This tool has been validated extensively in other settings and is therefore well‐suited for measuring D&A during childbirth.

A pre‐test of the questionnaire was conducted with a sample of 40 women (10% of the sample size). This was done to evaluate clarity and cultural relevance, as well as the ease with which the participants could process and respond to each question. Informed by the pre‐test, a number of necessary adjustments were made to refine the questions and ensure these would be appropriate for the target population.

After the pre‐test, a panel of experts in maternal health, public health, and epidemiology reviewed the questionnaire. This included expert feedback to improve the final content and structure of the D&A Framework itself to better address the spectrum of experiences contiguous with D&A. Also, to cover the meaning equivalence across languages, the questionnaire was back‐translated from English into Bangla. Discrepancies found by this process were addressed.

The questionnaire's reliability was assessed using Cronbach's α, which yielded a value of 0.77. A coefficient of 0.70 or higher is generally considered satisfactory, confirming the reliability of the tool for measuring the intended constructs [27]. Final adjustments to the questionnaire were made based on feedback from pre‐testing, expert reviews, and reliability testing including rewording of ambiguous items and incorporation of questions reflecting local concerns. Subsequently, the final questionnaire was piloted on two of its target community settings prior to the main data collection.

2.6. Measures

D&A care was operationalized using an adaptation of the seven categories described in Bowser and Hill's landscape analysis [23]. Indicators for observed events in D&A care were identified from the literature and the local context. The proportions for each D&A category were calculated using exit interview data. A total of 23 items measuring D&A care are spread across six domains in our study. A seventh domain related to detention was excluded, as this study focuses only on maternity care provided by community clinics in government health facilities without payment, and detention may result from unpaid medical bills.

Women who reported any of the following behaviors during childbirth at the health center were categorized under the respective forms of D&A: (1) physical abuse: kicking, pinching, slapping, pushing, beating, tying to the delivery bed/delivery couch or episiotomy without anesthesia; (2) non‐dignified care: shouting at, scolding, threating to withholding services, calling by insulting name, and laughing or scorning; (3) non‐consented care: abdominal palpation, vaginal examination, and episiotomy without the woman's; consent; (4) non‐confidential care: disclosing information related to sexually transmitted infection and other health information to non‐health staff, discussing personal issues within earshot of others; (5) lack of privacy: uncovering during delivery or examination, or no screens blocking view during delivery or examination; and (6) abandonment: leaving unattended during labor, while delivering, while experiencing complications or after delivery when a service will be needed.

Maternal satisfaction with care was assessed using two key measures: (1) whether the mother would recommend the same institution to others, and (2) whether she was satisfied with the treatment she received. Both items were evaluated on a five‐point scale (1) strongly disagree, (2) disagree, (3) neutral, (4) agree, and (5) highly agree. Participants' responses were categorized into two groups: Yes (strongly agree or agree), and No (strongly disagree, disagree, or neutral).

This study also collected the following covariates: (1) socio‐demographic characteristics such as age of women, respondent's education, household wealth index, healthcare decision‐making autonomy, occupation, religion, living in a patriarchal household and mass media exposure; (2) obstetric characteristics such as birth order, four or more antenatal care (ANC) visits, type of childbirth (vaginal/C‐section), presence of a companion during the childbirth and the length of stay for the recent delivery; and (3) healthcare provider characteristics such as types of delivery assistance, and number of delivery attendants. Data on household assets, such as possession of durable goods (like a radio, television, cell phone, landline phone, freezer, almirah/wardrobe, table, chair, watch, electric fan, and DVD/VCR player), transportation vehicle ownership (like a bicycle, motorcycle, scooter, or tempo, car/truck, rickshaw, van, or cart), agricultural land ownership (like a homestead or other agricultural land), and access to electricity, were used to create a wealth index.

As a rule of thumb in constructing this wealth index, factors with prevalences less than 3%–5% [28, 29] (e.g., sources of drinking water, sources of toilet facilities, access to power, car/truck, landline phone, and cart) were not included in the analysis while creating this wealth index. Principal component analysis was used to compute a weight (factor score) for each asset, and the resulting asset scores were then standardized to a standard normal distribution with mean zero and standard deviation one. After that, each asset was assigned a score, and the scores were summed for each family. After dividing the sample into terciles, each tercile was assigned a rank from 1 (poor) to 3 (rich), and people were graded based on their household's overall score.

2.7. Data Analysis

First, the accuracy of the gathered data and any missing or incorrectly loaded questions were manually checked. Double‐entry was used to verify the data entry. Any errors found during data entry were corrected by reviewing the questionnaire in its original form. Descriptive analyses (frequencies and percentages) were performed to determine mothers' sociodemographic, obstetric, provider‐level, D&A care, and satisfaction with care factors. Multivariable logistic regression analysis was used to examine the association between any D&A care and provider‐level, obstetric, and sociodemographic characteristics. Furthermore, two multivariable logistic regression models were created to investigate referrals to others and satisfaction with services received, using any D&A as an exposure variable.

To identify a significant association in the multivariable logistic regression analysis, a p value of less than 0.05 and 95% CIs for the adjusted odds ratio (AOR) were used. The appropriateness of the logistic regression models was evaluated using the Hosmer−Lemeshow goodness‐of‐fit test, where a good fit was defined as a nonsignificant p value (> 0.05). Since we believe each covariate is significant and may influence the results, we included all covariates in the regression models.

The standard errors of the regression coefficients were examined to verify multicollinearity in the logistic regression studies. Multicollinearity between the independent variables is indicated by a standard error greater than 2.0 [30]. There was no multicollinearity among the independent variables in the three multivariate logistic regression models, as shown by the standard errors of each independent variable being less than 1. The recommendations for Strengthening the Reporting of Observational Studies in Epidemiology were followed while reporting the study's data. All statistical calculations were performed using Stata version 15.0.

2.8. Ethical Approval and Informed Consent

The study received ethical clearance and formal authorization from the Institutional Review Committee of the Institute of Biological Sciences, University of Rajshahi, Bangladesh (NO: 336 (16)/1320/IAMEBBC/IBSC). Additionally, the responsible authority of the community clinics where data were collected provided letters of approval for the study. Informed consent was obtained from all participants prior to data collection. For literate participants, consent was obtained in writing. For illiterate participants, verbal consent was obtained and recorded using an audio recorder. This verbal consent process was used to ensure that participants fully understood the study's purpose and procedures. The audio recordings were securely stored on password‐protected devices, accessible only to authorized research staff. These recordings will be kept for 5 years for research purposes, after which they will be permanently deleted. For participants under 18, informed consent was obtained from a parent or legal guardian. Throughout the data collection process, confidentiality and anonymity were strictly maintained.

3. Results

3.1. Descriptive Statistics

The socio‐demographic characteristics of the sample are presented in Table 1. Most of the mothers (53%) were aged 25−34 years, and 20% had no formal education. The majority (90.8%) identified as Muslim. Around 15% of mothers lacked autonomy in healthcare decision‐making, and 83.5% were housewives. Regarding wealth, 31.3% were classified as rich, 68.1% engaged with mass media, and 88.3% lived in patriarchal households.

Table 1.

Socio‐demographic, obstetric, and healthcare provider characteristics (n = 400).

Characteristics	Number (N)	Percentage (%)
Maternal age, years
15–24	133	33.3
25–34	212	53.0
≥ 35	55	13.7
Education
No formal education	80	20.0
Primary school	162	40.5
Secondary school	108	27.0
College	35	8.7
Higher	15	3.8
Religion
Non‐Muslims	37	9.2
Muslims	363	90.8
Respondent working 1
Housewives	334	83.5
Private or government jobs	16	4.0
Small‐scale activities	50	12.4
Healthcare decision‐making autonomy 2
No	59	14.8
Yes	341	85.2
Living in a patriarchal household
No	47	11.7
Yes	353	88.3
Household wealth index
Poor	138	34.4
Middle	137	34.3
Rich	125	31.3
Mass media exposure 3
No	128	31.9
Yes	272	68.1
Birth order
First	83	20.8
Second	217	54.2
Third and more	100	25.0
Four or more ANC visits
No	240	59.9
Yes	160	40.1
Mode of delivery
Vaginal birth	329	82.3
Cesarean birth	71	17.7
Time of delivery
Day	257	64.3
Night	143	35.7
Birth companion
No	304	76.1
Yes	96	23.9
Length of stay for the recent delivery, days
1–2	275	68.7
> 2	125	31.3
Healthcare provider4
Doctor	178	44.6
Others	222	54.4
No of delivery attendants
≤ 2	245	61.3
> 2	155	38.7

¹ Small‐scale activities such as tailoring or other micro‐enterprises (selling food and livestock), rearing animals, day laboring, or domestic service.

² Women participated alone or jointly in the decision‐making on their own healthcare.

³ Watching television, listening to the radio, or reading the newspaper at least once a week.

⁴ Others: health assistant, nurse, midwife.

Table 1 also shows obstetric and healthcare provider characteristics. About 40.1% of mothers had four or more ANC visits, and 23.9% had a support person present during delivery. Vaginal birth was most common (82.3%), and 35.7% gave birth during the night. Most women (68.7%) stayed in the facility for 1−2 days post‐delivery. Doctors assisted with 44.6% of deliveries, and 61.3% had two or fewer attendants.

Table 2 shows that 25.8% of mothers experienced at least one form of D&A care. The most common types were abandonment of care (15.2%), followed by non‐dignified care (11.3%) and lack of privacy (9.5%). Physical abuse (3.9%), non‐consented care (7.8%), and non‐confidential care (8.2%) were also reported. Table 2 also presents satisfaction findings: 81.4% of women would recommend the facility, and 80.1% were satisfied with the care received.

Table 2.

Distribution of D&A care types and mothers' satisfaction with the services they received (n = 400).

Characteristics	Percentage (%)
Any form of D&A	25.8
Physical abuse	3.9
Kicked	0.1
Pinched	1.2
Slapped	1.3
Pushed	0.6
Beaten	0.2
Episiotomy without anesthesia	0.2
Tied to the delivery bed	0.3
Non‐confidential care	8.2
Discussed personal issues in earshot of other clients	5.1
Health information discussion with non‐health staff	4.6
Non‐consented care	7.8
Abdominal palpation	1.4
Vaginal examination	3.2
Episiotomy	5.1
Lack of privacy	9.5
No screen blocking view during delivery or examination	6.8
Uncovered during delivery or examination	4.9
Non‐dignified care	11.3
Shouted at	9.2
Scolded	5.9
Threatened to withhold services	7.0
Called by insulting name	0.2
Laughed at or scorned	0.2
Abandonment of care	15.2
While in labor	10.1
While delivering	8.2
While experiencing a complication	6.2
After delivery	7.2
Overall satisfaction with services received
Agree	80.1
Disagree/neutral	19.9
Recommendations to others	81.4
Agree, disagree/neutral	18.6

3.2. Multivariate Analyses

Multivariable logistic regression analysis (Table 3) reveals that mothers in the poor wealth bands were 3.63 times more likely (95% CI: 1.38−8.66) to receive D&A care than those in rich bands. Mothers who did not receive four or more ANC visits (AOR: 3.12, 95% CI: 1.75−5.91) or who had vaginal births (AOR: 3.86, 95% CI: 1.61−5.59) were also more likely to report D&A. First‐time mothers (AOR: 1.99, 95% CI: 1.19–4.04), women giving birth at night (AOR: 4.40, 95% CI: 1.81−9.20), or without birth companions (AOR: 3.51, 95% CI: 1.30−9.01) had a higher likelihood of D&A care. Women assisted by doctors had a significantly lower likelihood of reporting D&A care (AOR: 0.08, 95% CI: 0.03−0.34). The model's goodness‐of‐fit was confirmed with a p value of 0.790.

Table 3.

Adjusted odds ratio of the association between any D&A and maternal socio‐demographic, obstetric, and provider level characteristics (n = 400).

Characteristics	Any form of D&A
	Adjusted odds ratio	95% CI
Maternal age, years
15–24	0.12	0.02–1.57
25–34	0.91	0.42–1.81
≥ 35	1.00	—
Education
No formal education	1.64	0.79–3.61
Primary school	1.74	0.62–4.82
Secondary school	1.96	0.51–6.23
College	0.77	0.31–2.21
Higher	1.00	—
Religion
Non‐Muslims	0.59	0.24–1.34
Muslims	1.00	—
Respondent working
Housewives	0.61	0.27–1.37
Private or government jobs	0.59	0.44–2.01
Small‐scale activities	1.00
Healthcare decision making autonomy*
No	0.62	0.37–1.69
Yes	1.00	—
Living in a patriarchal household
No	1.90	0.41–9.3
Yes	1.00	—
Household wealth index
Poor	3.63b	1.38–8.66
Middle	1.61	0.71–4.5
Rich	1.00	—
Mass media exposure
No	0.81	0.19–5.19
Yes	1.00	—
Birth order
First birth	1.99c	1.19–4.04
Second	0.78	0.47–1.39
Three and above	1.00	—
Four or more ANC visits
No	3.12c	1.75–5.91
Yes	1.00	—
Mode of delivery
Vaginal birth	3.86a	1.61–5.59
Cesarean birth	1.00	—
Time of delivery
Night	4.40b	1.81–9.20
Day	1.00	—
Healthcare provider
Doctors	0.08b	0.03–0.34
Others	1.00	—
Length of stay for the recent delivery, days
1–2	1.27	0.78–3.12
> 2	1.00	—
Birth companion
No	3.51c	1.30–9.01
Yes	1.00	—
No of delivery attendants
≤ 2	0.69	0.51–1.29
> 2	1.00	—

Note: Here a, b, and c indicate p < 0.001, p < 0.01, and p < 0.05; Hosmer–Lemeshow goodness‐of‐fit test Prob > chi‐squared = 0.790.

^*Healthcare decision making autonomy refers to a woman's ability to participate in decisions regrading her own or family member's health care, either independently or jointly with her husband/partner or another household member.

The logistic regression analysis (Table 4) shows that women who did not experience D&A care were 3.35 times more likely to report satisfaction (AOR: 3.35, 95% CI: 2.81−5.81) and 2.74 times more likely to recommend the facility (AOR: 2.74, 95% CI: 1.95−4.23) compared to those who experienced D&A care. The goodness‐of‐fit results for satisfaction (p = 0.441) and recommendation (p = 0.937) indicated that the model was a good fit.

Table 4.

Adjusted odds ratio of the association between level of satisfaction and any D&A care (n = 400).

Characteristics	Satisfaction with services received1		Recommendations to others2
	Adjusted odds ratio	95% CI	Adjusted odds ratio	95% CI
Any D&A
No	3.35c	2.81−5.81	2.74c	1.95−4.23
Yes	1.00	—	1.00	—

Note: ^{1, 2} Models were adjusted by maternal age, education, occupation, religion, healthcare decision‐making autonomy, living in a patriarchal family, household wealth, mass media exposure, birth order, four or more ANC visits, mode of delivery, time of delivery, types of healthcare provider, length of stay during delivery, birth companion, and number of delivery attendants. Here a, b, and c indicate p < 0.001, p < 0.01, and p < 0.05; ^1,2 Hosmer–Lemeshow goodness‐of‐fit test Prob > chi‐squared = 0.441 and 0.937.

4. Discussion

4.1. Major Findings

This study is the first to examine the prevalence of D&A during facility‐based deliveries in rural Bangladesh, its impact on women's satisfaction, and the factors influencing D&A care. Key findings are: (1) over 25% of women in rural Bangladesh experienced D&A during facility‐based births; (2) women who reported D&A were significantly less satisfied with their care and less likely to recommend the facility to others; and (3) the likelihood of experiencing D&A care was higher among women with poor wealth, first‐time mothers, those who received fewer than four ANC visits, those giving birth at night, or those without a birth companion.

4.2. Comparison With Other Studies

Our results suggest that there is a higher proportion of D&A care in rural areas of Bangladesh. The results are similar to those in rural Tanzanian [31, 32], Pakistani [33], and Kenyan [34] studies, which reported comparable prevalence rates. The recent study by Limmer et al. [22] indicates that D&A care is universal across Germany, with more than three‐fourths of women having had experienced some miserable form of treatment by caregivers during childbirth. This indicates that D&A are widespread among women from all around the world and are not exclusive to low‐resource settings.

Our research shows that women's experiences with D&A care lowered their likelihood of recommending the facility to others and their degree of satisfaction with the care they received. As a result, lowering D&A is crucial for raising standards of care and encouraging confidence in healthcare facilities. Despite the lack of research on this topic, our results are consistent with studies conducted in low‐income countries that have highlighted the significant connection between D&A care and women's satisfaction with care [35, 36] and whether they would recommend the facility to others [36].

Our findings also support existing research [37, 38, 39, 40, 41, 42, 43], linking poor levels of wealth with higher rates of D&A. This difference in treatment could be explained by the possibility that healthcare professionals may treat affluent women with greater deference, although this may also reflect differences in how socioeconomically diverse populations are perceived in healthcare settings. According to our results, first‐time mothers were more likely to experience D&A care than mothers who had given birth three or more times, which is consistent with previous studies [44, 45]. These differences may be explained by two possibilities: first, women with higher birth orders may have lower expectations of the care they would receive during childbirth because they are more accustomed to the childbirth process and frequent medical procedures. Alternatively, prior experiences of mistreatment may normalize disrespectful treatment among some women.

Nonetheless, a more structural explanation also warrants consideration: first births are often longer, involve more interventions, and are medically complex, which increases both the opportunity and likelihood of encountering disrespectful or coercive care. In contrast, subsequent births tend to be quicker and less medically demanding, potentially reducing the likelihood of D&A events. Understanding the parity differences in D&A care in terms of these structural factors would enable a more comprehensive interpretation of the results.

Women with fewer than four ANC visits were also more likely to report D&A care, suggesting that through regular ANC visits, a woman can build trust with the healthcare providers, increase her knowledge of maternity care, and empower her to challenge mistreatment [46, 47]. This finding underscores the need for increased access to comprehensive ANC for all pregnant women.

The analysis also suggested that women who had vaginal deliveries were more inclined to have D&A care which could be linked either with pain or perhaps a sense of lack of control over their bodies. Health professionals behaving aggressively toward women during delivery could further infringe their rights and autonomy. Similar concerns regarding mistreatment during vaginal births raised from China [48] and Palestine [44] as well.

The likelihood of D&A care was likely to be experienced by women whose deliveries were at night, probably due to reduced staff availability or the tiredness of caregivers during night shifts. Previous studies [34, 41, 49] carried out in other low‐resource contexts indicated that more respect was given to women delivering in the daytime rather than at night to show that staffing levels and work conditions can hugely influence the quality of maternity care students receive.

Finally, our results show that women without birth companions were more likely to report D&A care, which is consistent with the protective role of birth companions noted in existing literature [50, 51]. However, patients who did not have companions present in the delivery room were more likely to have received D&A care services. This difference might be attributed to the variations in hospital policy or cultural practice regarding companions' presence, which then impacts on the overall care experience. They might suggest introducing birth companions into the care process as an easy and effective way to improve care and ensure women's rights in labor.

4.3. Obstetric Violence and Its Conceptual Framing

In this study, the term D&A is adopted in reference to how women are mistreated during childbirth in healthcare services in line with the definition as given by the World Health Organization (WHO). There is, however, another conceptual framework that could present the notion of D&A; one that is sometimes mobilized in feminist, legal, sociological, or rights‐based literature: Obstetric violence [52, 53]. Obstetric violence stands for the systematic ill‐treatment of women during childbirth, particularly with reference to gendered power dynamics and structural inequalities in the healthcare system [53].

While the D&A framework accurately captures and reflects the nature of mistreatment during birth, regarding something like it as this term, obstetric violence, serves to broaden the conception of maternal mistreatment, particularly in its structural and gendered dimensions that account for most forms of abuse or mistreatment in mothers. This term includes physical violence, verbal abuse, and the denial of women's autonomy, but also stresses the institutionalized discrimination and gendered violence inherent in maternity care. Obstetric violence connects the issue of mistreatment to broader human rights concerns and the need for structural change within health systems.

Although this study adopts the D&A framework, acknowledging obstetric violence allows for a deeper conceptual understanding of mistreatment during childbirth. As noted by Sadler et al. [54], the concept of obstetric violence situates maternal mistreatment within a rights‐based framework and highlights the human rights violations that women face during childbirth. Recognizing both D&A and obstetric violence enriches the theoretical contribution of this study and situates it within a broader, interdisciplinary conversation about gender equality and social justice in maternal healthcare.

4.4. Strengths and Limitations

This study has several strengths. It is one of the earliest studies to quantify the prevalence of D&A during facility‐based childbirth in rural Bangladesh and explore its association with maternal satisfaction. Structured face‐to‐face interviews allowed for a high response rate and completeness.

Several limitations should be considered. First, the cross‐sectional design of this study precludes causal inference between D&A and maternal satisfaction. Second, the results are based on interview data that were self‐reported and may be prone to recall and social desirability bias since interviews were conducted in health facilities. Third, the study was limited to women who delivered in selected community clinics, thereby introducing potential for selection bias and limiting generalizability to home deliveries or women delivering in other types of facilities.

Fourth, maternal satisfaction was measured with two indicators, which may not fully cover its multidimensional nature. In future research, the use of validated comprehensive measures may provide a more nuanced assessment. Lastly, the study was conducted in a small number of rural facilities in one district which might limit external validity for other settings.

4.5. Policy Implications

The findings from this study suggest several policy recommendations aimed at reducing D&A during facility‐based deliveries and improving overall maternal care. First, it seems highly necessary to ensure that enough providers are available for duty during the night, as women giving birth at night were shown to be at greater risk of D&A care. With the extra presence of qualified professionals, basically doctors, during the night shift, some of the adverse effects of shortage of staff and fatigue can be mitigated, which gives rise to mistreatment.

Another recommendation of equal significance would be to create an enabling environment for the choice of birth companions during delivery. Our study highlighted that women delivering without birth companions were more likely to report D&A care. Recent policies should be reviewed to allow and actively promote the presence of birth companions in the delivery room, as their emotional preparation could serve as an advocacy tool for ensuring that women are provided with respectful care throughout the childbirth process.

The study also emphasizes the need to increase access to comprehensive ANC, because women who found themselves receiving less than four ANC visits were more likely to report experiencing D&A. Therefore, policies need to focus on expanding access to good quality ANC itself, as it would improve maternal health outcomes and at the same time establish a trust‐based relationship between the woman and healthcare providers, hence warranting her self‐advocacy during delivery.

In addition, the policies must ensure access to quality maternity care for these women, possibly through outreach programs, subsidies, or tailored support services. Such focused measures should be undertaken by and aimed at the vulnerable groups, which would include women at the lower end of wealth bands and first‐time mothers, as well as those who did not receive adequate ANC.

Most importantly, it is important that health workers receive periodic instruction on respectful maternity care, covering issues of professionalism, communication skills, and patient rights to create a respectful and dignified atmosphere. All this training will deal with the systemic and structural issues that underpin D&A during childbearing.

5. Conclusions

More than one in four of the women in our research experienced D&A care during a facility‐based birth, indicating that D&A care during institutional delivery was relatively common in rural Bangladeshi settings. Women's satisfaction with institutional delivery is negatively affected by D&A care during delivery, as our study shows. The following variables were associated with a greater likelihood of D&A care disclosure: first‐time mothers, mothers who gave birth vaginally or without four or more ANC visits, women who were in the poor bands of wealth, mothers who gave birth at night or without birth companions present, and mothers who received assisted birth other than by a doctor. Thus, there should be a program to raise health workers' knowledge of the need to enhance the standard of medical care provided at night in all medical facilities, with an emphasis on first‐time mothers, vaginal delivery mothers, and economically disadvantaged women. Furthermore, all pregnant women should be encouraged to attend four or more ANC visits, and medical facilities should be encouraged to promote doctors to provide assisted births. Additionally, policies must be modified to permit companions to be present in the labor or delivery room. Although the current study is relevant to the local area, where it is crucial to prioritize expectant mothers' physical and mental health during childbirth, our findings may also be applicable in other settings with limited resources, where access to skilled childbirth services is low, and maternity care is of poor quality.

Author Contributions

M.R. originated the study and contributed to study design, statistical analysis, and the writing of the article. P.S. S.E.H., T.K.R., M.R.A., M.H., I.F.A., N.C.H.D., S.A.‐S., H.S., and S.D. contributed to the analysis and interpretation of data and to revisions of the article. All authors read and approved the final manuscript.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The corresponding author, Mosiur Rahman, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.