Mistreatment during childbirth and its associated factors during facility-based childbirth in public health facilities of Ilubabor Zone, Southwest Ethiopia

Abstract

Background

Mistreatment during childbirth remains a barrier to maternal health in low-resource settings.

Objective

To assess the prevalence of mistreatment during childbirth and its associated factors among women in public health facilities of Ilubabor Zone, Southwest Ethiopia, 2025.

Methods

A facility-based cross-sectional study was conducted from August to October 2025 among 470 women using multistage sampling and interviewer-administered questionnaires. Data were analyzed with descriptive statistics and multivariable logistic regression.

Results

Mistreatment during childbirth was reported by 68.1% (95% CI: 63.9–72.3%) of women. Verbal insults, denial of mobility during labor, refusal of pain relief, and lack of consent for procedures were the most common forms. Significant factors included low maternal education (AOR = 7.10, 95% CI: 3.71–13.58), observed provider burnout (AOR = 3.30, 95% CI: 2.14–5.10), and high provider workload (AOR = 2.70, 95% CI: 1.80–4.06).

Conclusion

High prevalence of mistreatment was observed, driven by low maternal education and multiple provider- and system-level factors. Enhanced training, staffing, and community education are urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-026-00275-6.

Introduction

Despite substantial global progress in maternal health, maternal mortality remains a critical public health challenge, claiming approximately 260,000 lives annually from pregnancy-related causes, with the greatest burden occurring in low- and middle-income countries (LMICs), particularly in sub-Saharan Africa [1]. Although the global maternal mortality ratio (MMR) declined by about 40% between 2000 and 2023, reaching 197 per 100,000 live births, increased facility-based deliveries from 5% in 2000 to 64% in 2024–25, the pace of reduction remains insufficient to meet the Sustainable Development Goal (SDG) target of fewer than 70 deaths per 100,000 live births by 2030. Therefore, it provides timely evidence to evaluate the implementation of the CRC initiative at the rural facility level in a geographically and socioeconomically disadvantaged zone [2].

Beyond mortality, mistreatment during childbirth has emerged as a serious barrier to improving maternal health outcomes. The World Health Organization defines mistreatment as physical abuse, verbal humiliation, stigma and discrimination, non-consented clinical procedures, breaches of confidentiality, neglect, and unlawful detention during facility-based child. It adopted the typology developed by Bohren et al. to operationalize and measure the different forms of mistreatment [3, 4]. Earlier conceptual work highlighted disrespect and abuse as systemic violations embedded within maternity care systems [5]. Such practices constitute violations of women’s fundamental rights and can erode trust in healthcare systems, discourage facility-based delivery, and ultimately hinder reductions in maternal mortality [6].

Globally, mistreatment during childbirth affects a substantial proportion of women. A recent systematic review and meta-analysis reported a pooled prevalence of 54.5%, with estimates ranging widely across settings [7]. A multi-country study conducted in Ghana, Guinea, Myanmar, and Nigeria found that over one-third of women experienced mistreatment during childbirth, with 42% reporting physical or verbal abuse, stigma, or discrimination, disproportionately affecting younger and less-educated women [4]. In high-income countries such as the United States, prevalence ranges from 13.4% to 20%, rising to nearly 30% among marginalized populations [8, 9]. In LMICs, reported levels are generally higher, reaching 40% in urban India and 43% in parts of Latin America [10]. Systemic drivers in under-resourced health systems—including overcrowding, inadequate training, hierarchical workplace culture, and normalization of gender-based violence contribute to these occurrences [11, 12]. The consequences are profound, including increased risks of postpartum depression, maternal and neonatal complications, and long-term avoidance of healthcare facilities [13].

In sub-Saharan Africa, pooled evidence indicates that approximately 44% of women experience mistreatment during childbirth exacerbated by chronic understaffing and limited infrastructure [14]. Ethiopia reflects these regional challenges while demonstrating improvements in maternal health indicators. The pregnancy-related mortality ratio declined from 871 per 100,000 live births in 2000 to 169 in 2025, and the maternal mortality ratio (MMR) stands at 141 per 100,000 live births in 2025 [2]. National efforts, including free maternity services and expansion of community-based programs have increased facility-based deliveries from 5% in 2000 to 48% in 2019 [15, 16].

Nevertheless, mistreatment during childbirth remains widespread in Ethiopia, with reported prevalence ranging from 49.4% to 91.7% across different regions [17]. Facility-based studies documented prevalence of 67.1% in Bahir Dar and 74.8% in Western Ethiopia [18, 19]. In rural settings such as Ilubabor Zone in Oromia Region, characterized by limited infrastructure, poverty, and ethnic diversity evidence on this issue remains scarce. This lack of localized data constrains implementation of Ethiopia’s Compassionate, Respectful, and Caring (CRC) initiative under the Health Sector Transformation Plan II [20, 21]. Furthermore, mistreatment undermines progress toward the SDGs related to health and gender equality [22] and may reinforce distrust in formal healthcare systems within marginalized communities [23].

Evidence suggests that mistreatment arises from interconnected determinants. Socio-demographic vulnerabilities such as low income, rural residence, and limited antenatal care attendance increase risk [17, 24]. Obstetric factors, including primiparity, obstetric complications, nighttime delivery, and absence of a birth companion are also associated with higher exposure [19, 24]. Provider-related contributors such as gender bias, burnout, and hierarchical workplace norms further sustain disrespectful practices [12, 25]. Despite national respectful maternity care policies, implementation gaps persist in rural settings, necessitating context-specific evidence to guide interventions [21].

Although previous studies have documented the magnitude of mistreatment during childbirth in Ethiopia and sub-Saharan Africa, important gaps remain. Most existing evidence is derived from urban or hospital-based settings, with limited representation of remote, socioeconomically disadvantaged zones such as Ilubabor. Furthermore, prior studies have largely focused on conventional sociodemographic and obstetric predictors, with less attention to contextual and health-system–related factors, including facility readiness, provider workload, and companionship during labor, cultural congruence of care, and women’s awareness of respectful maternity care rights. These contextual dynamics are particularly relevant in rural Oromia, where geographic barriers, ethnic diversity, and resource constraints may uniquely shape childbirth experiences. Generating localized, up-to-date evidence that incorporates these additional dimensions is essential for designing targeted, context-responsive interventions. Therefore, this study aims to assess the prevalence of mistreatment and associated factors among laboring mothers in Ilubabor Zone, Southwest Ethiopia, in 2025. By identifying setting-specific determinants, this study will provide actionable insights to strengthen respectful maternity care implementation, improve institutional delivery uptake, and support Ethiopia’s Compassionate, Respectful, and Caring (CRC) initiative and Sustainable Development Goal commitments.

Methodology

Study area and period

This study was conducted in Ilubabor Zone, Oromia Region, South-West Ethiopia, from August 1, 2025, to October 31, 2025. Ilubabor is recognized as one of the 20 zonal administrations within the Oromia Regional State, located approximately 600 km to the southwest of Addis Ababa, the capital of Ethiopia. As of 2020, the total population of this zonal administration was recorded at 968,303, encompassing 14 rural woredas, one town administration, 23 urban kebeles, and 263 rural kebeles. The zone is equipped with sufficient healthcare infrastructure, which includes two hospitals, 29 health centers, and 263 health posts, staffed by a total of 1,114 health workers across various professional categories, in addition to 606 supportive staff members. This workforce primarily consists of nurses, followed by midwives, general practitioners, and a limited number of specialists such as gynecologists and obstetricians, concentrated in urban facilities like Mattu Karl Comprehensive Specialized Referral Hospital (MKCSRH). The zone’s maternal health profile reflects broader Oromia challenges, with an annual crude birth rate of 24.2 per 1,000 population yielding 23,450 live births and a total fertility rate of 5.0 children per woman supporting 117,250 pregnancies among women of reproductive age (15–49 years, approximately 48% of the population or 464,785 individuals). Institutional delivery rates average 64% nationally as per the 2024–25 Ethiopia Demographic and Health Survey [2], but are constrained in Ilubabor by rural isolation and cultural preferences for home births, which heighten risks of dehumanized maternity care in under-resourced settings. These dynamics, amid a predominantly agricultural economy and modest literacy rates (40–50% among adults), underscore Ilubabor’s importance as a site for targeted research on respectful maternity care.

Study design

A facility-based cross-sectional study design was employed. This design was chosen to capture a snapshot of experiences during childbirth across multiple facilities, allowing for robust statistical analysis of prevalence and associated factors within the study period.

Source population and study population

The source population included all laboring mothers who delivered in public health facilities within Ilubabor Zone during the study period. The study population consisted of laboring mothers who met the inclusion criteria and delivered in selected public health facilities during the data collection period. This approach ensured a representative sample of women accessing maternity care in government-owned facilities.

Inclusion and exclusion criteria

Inclusion Criteria: Eligible participants were laboring mothers who gave birth in public health facilities in Ilubabor Zone during the study period and provided informed consent to participate.

Exclusion Criteria: Mothers who were critically ill or unable to communicate due to medical conditions (e.g., severe obstetric complications or mental health issues) were excluded, as were those who delivered outside public health facilities (e.g., home births) or in private facilities. These criteria ensured that data collection focused on women capable of providing reliable responses and receiving care in the study’s target settings.

Sample size determination

The sample size was calculated using the single population proportion formula: n = (Z² × p × (1-p)) / d², assuming a 95% confidence level (Z = 1.96), 5% margin of error (d = 0.05), and a prevalence of mistreatment of 74.8% from a previous study in Western Ethiopia [17]. This yielded n ≈ 290, which was adjusted to 435 after applying a 1.5 design effect for multistage sampling. Accounting for a 10% non-response rate, the final target sample size was 479. In practice, 470 laboring mothers were interviewed (98.1% response rate), with 9 non-responses due to refusal to participate (n = 5) and severe postpartum fatigue/medical condition preventing interview (n = 4). Post-hoc power calculation for key associations (e.g., low maternal education) exceeded 80% at α = 0.05.

Sampling technique

A multistage sampling approach was employed. First, Ilubabor Zone was stratified by administrative woredas, and a subset was randomly selected proportional to population size to ensure urban-rural representation. Second, one hospital and eight health centers offering maternity services were purposively selected from the chosen woredas to capture facility-type variation. The target sample of 479 was proportionally allocated to these nine facilities based on their average two-month delivery caseload from the previous year (total ≈ 1,260 deliveries). Third, systematic random sampling was applied within each facility: the sampling interval k ≈ 3 was calculated overall (1,260 ÷ 479 ≈ 2.63, rounded to 3), with proportional allocation per facility (e.g., facility-specific intervals derived from individual caseloads). The first eligible mother in each facility was randomly selected, followed by every third thereafter until the allocated quota was reached (Fig. 1).

Fig. 1.

Flow diagram of the multistage sampling procedure for selecting laboring mothers at public health facilities in Ilubabor Zone, Southwest Ethiopia, 2025

Study variables

Dependent Variable: Prevalence of mistreatment during childbirth (yes/no).

Independent Variables:

Socio-demographic factors: Age, education level, occupation, marital status, household income, residence (urban/rural), ethnicity, religion.

Obstetric factors: Parity, antenatal care (ANC) attendance (number of visits), previous birth experiences, mode of delivery (vaginal/caesarean), labor complications, gestational age.

Health system factors: Type of facility (hospital/health center), time of delivery (day/night), presence of birth companion, provider gender and profession, facility workload. This comprehensive variable set enabled a thorough exploration of factors influencing dehumanized maternity care.

Data collection instrument

Data were collected using a semi-structured, interviewer-administered questionnaire adapted from validated instruments, including the WHO multi-country study on mistreatment [7] and prior Ethiopian studies [16–18]. The questionnaire included sections on socio-demographic characteristics, obstetric history, experiences of mistreatment (assessed via a Likert scale for frequency and yes/no for occurrence), and associated factors. Provider-related items (e.g., job satisfaction, burnout, compassion/empathy, approachability, workload, salary adequacy, knowledge of respectful maternity care) were measured through maternal perceptions using binary (Yes/No) responses. The pretest on 24 mothers yielded a Cronbach’s alpha of 0.73 for the entire instrument, including the provider-perception subscale, confirming acceptable internal consistency for these perception-based items. To ensure cultural and linguistic appropriateness, the questionnaire was translated into Afan Oromo and Amharic, with back-translation to English to verify accuracy. A pretest was conducted on 5% of the sample (24 mothers) at Bedele General Hospital, yielding a Cronbach’s alpha of 0.73, indicating acceptable internal consistency. Revisions post-pretest improved question clarity and respondent comprehension, ensuring the tool’s validity and reliability for the study context.

Data collection process

Data collection was conducted by nine trained midwives external to the study facilities to minimize bias and ensure impartiality. Face-to-face interviews were conducted in private postnatal rooms within 24 h postpartum, after confirming participants’ recovery and obtaining informed consent. Interviews, lasting 20–30 min, were conducted in a confidential setting to reduce social desirability bias and encourage honest responses. Private postnatal interviews by external midwives, confidentiality assured, no facility staff present, voluntary/no incentives. Two trained supervisors oversaw daily activities, ensuring adherence to protocols and addressing any issues promptly. Data collection occurred daily throughout the study period to minimize recall bias. Ethical considerations, including voluntary participation, confidentiality, and the right to withdraw, were strictly upheld to protect participants.

Data quality assurance

Multiple measures ensured data quality. The questionnaire was pretested and refined to enhance clarity and reliability. Data collectors and supervisors received two days of training on the questionnaire, ethical procedures, and interview techniques to standardize data collection. Supervisors conducted daily checks for completeness and consistency, correcting errors immediately. Missing data were managed through imputation for minimal cases (< 5%) or exclusion if extensive, ensuring robust data integrity and minimizing bias.

Operational definitions

Mistreatment: Experiencing at least one form of mistreatment during childbirth, categorized per Bohren et al.’s typology: physical abuse (e.g., slapping, pinching), verbal abuse (e.g., shouting, insults), non-consented care (e.g., procedures without permission), non-confidential care (e.g., lack of privacy), non-dignified care (e.g., humiliation), discrimination (e.g., based on ethnicity or income), abandonment/neglect, or detention in facilities [4].

Laboring Mother: A woman in active labor or within 24 h postpartum in a public health facility.

Public Health Facility: Government-owned health centers or hospitals providing maternity services in Ilubabor Zone.

Adequate Antenatal Care: At least four ANC visits during pregnancy, as recommended by WHO [1].

Zone: An administrative division in Ethiopia, equivalent to a region or province, comprising multiple woredas (districts) with shared governance and health infrastructure, as defined by the Ethiopian government [2].

Woreda: A district-level administrative unit within a zone, responsible for local governance and service delivery, including health facilities. These definitions ensured standardized measurement and clarity of key terms for the study context.

Data analysis

Data were cleaned in EpiData v3.1 and analyzed in SPSS v26. Descriptive statistics summarized characteristics and prevalence. Bivariable logistic regression identified associations (p < 0.25 criterion for multivariable entry). All variables retained in the final multivariable model were selected a priori based on the conceptual framework presented in the introduction and existing literature, thereby minimizing overfitting. The final multivariable model included 10 significant variables (Supplementary Table S1). Post-hoc power was > 80% for major predictors. Model fit was assessed via Hosmer-Lemeshow test (p = 0.72), and multicollinearity via VIF (all < 3.5).

Ethical considerations

Ethical approval was obtained from the Institutional Review Board (IRB) of Mattu University, College of Health Sciences, Department of Midwifery (Ref: MDD/553/2025). Written informed consent was secured from all participants aged 18 years and older. For participants under 18 years, parental or guardian consent was obtained, with assent from the minor, documented by the interviewer in the presence of an independent witness to verify understanding and agreement. Data were anonymized using unique identifiers, stored securely on password-protected systems, and accessible only to the research team. No incentives were provided to participants to avoid coercion, in line with ethical guidelines for research in low-resource settings and the Declaration of Helsinki. Participants were informed of their right to withdraw at any time without consequences. Findings will be disseminated to local health authorities to inform policy and enhance maternity care practices in Ilubabor Zone.

Clinical trial number

Not applicable.

Results

Socio-demographic characteristics of respondents

A total of 470 postpartum women were interviewed (98.1% response rate). The mean age was 29.8 ± 6.4 years. Low education predominated (30.0% could not read or write, while rural residence (57.2%) and housewifery (40.6%) were common (Table 1).

Table 1.

Socio-demographic characteristics of laboring mothers at public health facilities in ilubabor zone, oromia region, Southwest Ethiopia, 2025 (n = 470)

S/No	Questions	Category	Frequency	Percentage
100	Age of the respondents	15–19	37	7.9
		20–24	84	17.9
		25–29	127	27.0
		30–34	102	21.7
		≥ 35	120	25.5
	Mean age (± SD)		29.8 (± 6.4)
101	Residence	Urban	201	42.8
		Rural	269	57.2
102	Marital status	Single	47	10.0
		Married	364	77.4
		Divorced	38	8.1
		Widowed	21	4.5
103	Educational status	Can’t read and write	141	30.0
		Primary school	165	35.1
		Secondary school	117	24.9
		College and above	47	10.0
104	Religion	Protestant	236	50.2
		Muslim	185	39.4
		Orthodox	33	7.0
		Traditional	16	3.4
105	Ethnicity	Oromo	391	83.2
		Amhara	47	10.0
		Tigre	14	3.0
		South Nations, Nationalities, Peoples & Nuer	18	3.8
106	Occupation	Government employment	109	23.2
		Housewife	191	40.6
		Student	170	36.2
107	Husband’s occupation	Government employment	135	28.7
		Farmer	223	47.4
		Merchant	112	23.8
108	Family income per month	≤ 2000 ETB	189	40.2
		2000–5000 ETB	205	43.6
		≥ 5000 ETB	76	16.2

Obstetric and healthcare access characteristics

Among the study participants, 98 (20.9%) had one live child, 283 (60.2%) had between two and five children, and 89 (18.9%) reported having more than five children. Regarding access to healthcare, 164 (34.9%) of respondents reached the nearest health facility in less than 30 min, 205 (43.6%) required 30–60 min, and 101 (21.5%) traveled more than one hour. In terms of antenatal care (ANC) utilization, 67 (14.3%) of women had only one ANC visit, 298 (63.4%) attended two to four visits, and 105 (22.3%) completed more than four visits during their current pregnancy.

Regarding place of delivery, most (71.9%) delivered in health centers, while 28.1% gave birth in hospitals. Deliveries occurred slightly more during the daytime (55.5%) than at night (44.5%). Only 27.2% were allowed a birth companion, indicating limited adherence to supportive labor practices. Regarding providers, 60.4% of women were attended by female staff, with midwives or nurses assisting the majority of deliveries (72.6%), followed by doctors (17.7%) and other health professionals (9.8%). Informed consent was often lacking, as only 34.5% of women reported that procedures were explained before being performed.

Facility conditions posed additional challenges: just 42.1% of respondents perceived the environment as clean and well-equipped, while 57.9% noted deficiencies. Overcrowding and long waiting times were reported by 59.1% of women, reflecting systemic constraints that may compromise the quality of maternal care.

Prevalence of mistreatment during childbirth

Overall, 68.1% (95% CI: 63.9–72.3%) of mothers reported at least one form of mistreatment. The most common manifestations were verbal insults (66.0%), denial of mobility during labor (68.1%), refusal of pain relief requests (66.0%), lack of consent for procedures (63.8%), and threats/intimidation (61.7%). Other frequent experiences included being ignored/left unattended (57.4%), unnecessary repeated vaginal examinations without consent (59.6%), and separation from the newborn without medical reason (31.9%) (Table 2).

Table 2.

Prevalence of mistreatment during childbirth by Bohren et al. typology domains among laboring mothers at public health facilities in ilubabor zone, Southwest Ethiopia, 2025 (n = 470)

Domain (Bohren et al.)	Prevalence (%)	n/470	95% CI	Key Examples from Questionnaire (most common items)
Verbal abuse	66.0	310	61.6–70.4	Shouted at/scolded/verbally insulted; threatened/intimidated
Non-consented care	63.8	300	59.3–68.3	Procedures performed without consent; unnecessary repeated vaginal examinations without consent
Denial of mobility / Physical restraint	68.1	320	63.9–72.3	Not allowed to move freely during labor; physically restrained/tied down
Refusal of pain relief / Neglect	66.0	310	61.6–70.4	Ignored/refused requests for pain relief or assistance; left unattended/ignored
Physical abuse	40.4	190	35.9–44.9	Physically mistreated (slapped, pinched)
Discrimination	38.3	180	33.9–42.7	Discriminated against due to ethnicity, age, economic status, etc.
Abandonment / Non-dignified care	57.4	270	52.8–62.0	Left unattended/ignored; separated from newborn without medical reason
Overall mistreatment	68.1	320	63.9–72.3	Experienced at least one form of mistreatment

Maternal and neonatal outcomes and satisfaction with care

Among the 470 laboring mothers included in the study, 75 (16%) experienced complications during labor or delivery that were not adequately managed, while the majority, 395 (84%), reported no such complications. In terms of neonatal outcomes, most mothers (420; 89.4%) reported that their newborns were healthy immediately after birth, whereas 50 (10.6%) indicated adverse neonatal outcomes.

Maternal satisfaction with the care received showed considerable variability. Only 180 (38.3%) mothers reported being satisfied or very satisfied, while 150 (31.9%) were dissatisfied, 80 (17%) were neutral, and 60 (12.8%) were very dissatisfied. Notably, despite the high prevalence of mistreatment, a substantial proportion of mothers (350; 74.5%) stated that their childbirth experience would encourage them to utilize facility-based delivery in the future, suggesting a complex interplay between care quality, perceived mistreatment, and willingness to seek institutional services. This apparent paradox of high reported mistreatment yet substantial willingness to return for future deliveries is explored further in the discussion.

Provider-related and work environment factors

In this study, 55 (11.7%) reported a prior mental health diagnosis, and 95 (20.2%) received psychosocial support during childbirth. While 360 (76.6%) mothers reported that healthcare providers communicated in their preferred language, only 190 (40.4%) felt that their cultural beliefs were respected. Only 40.4% (190) of respondents perceived that the facility had adequate staffing. Interestingly, the prevalence of mistreatment was higher among those who perceived staffing as adequate (74.7%) compared to those who perceived it as inadequate (63.6%). This counterintuitive finding is further discussed in discussion section (Table 3).

Table 3.

Psychosocial, cultural, and economic characteristics of laboring mothers at public health facilities in ilubabor zone, Oromia Region, Southwest Ethiopia, 2025 (n = 470)

Category	Questions	Response	Frequency (n)	Percentage (%)
Psychosocial & Mental Health	Ever diagnosed with mental health condition before this pregnancy?	Yes	55	11.7
		No	415	88.3
	Received psychosocial support during/after childbirth	Yes	95	20.2
		No	375	79.8
Cultural Respect	Providers communicated in preferred language	Yes	360	76.6
		No	110	23.4
	Cultural beliefs and practices respected	Yes	190	40.4
		No	280	59.6
Economic & Access Barriers	Had health insurance or payment arrangement	Yes	220	46.8
		No	250	53.2
	Payment/insurance affected quality of care	Yes	380	80.9
		No	90	19.1
	Transportation to facility was timely and reliable	Yes	190	40.4
		No	280	59.6
	Referred from another facility	Yes	150	31.9
		No	320	68.1
Facility Staffing & Patient Rights	Providers had enough staff to provide care	Yes (Adequate)	190	40.4
		No (Inadequate)	280	59.6
	Aware of rights as a patient during childbirth	Yes	180	38.3
		No	290	61.7
	Felt confident to express concerns and preferences	Yes	175	37.2
		No	295	62.8
Previous Birth Experience	Previously gave birth at home/with traditional birth attendant	Yes	160	34.0
		No	310	66.0

† Counterintuitive pattern: Mothers who perceived adequate staffing reported a higher prevalence of mistreatment (74.7%) compared to those who perceived inadequate staffing (63.6%)

Health care providers related characteristics

Among the 470 laboring mothers surveyed, a striking majority perceived systemic and provider-related factors that may compromise the quality of maternity care. More than half of respondents (57.4%) reported that healthcare providers did not receive adequate salary and benefits, and 66% felt that providers lacked sufficient training in respectful maternity care. Furthermore, 63.8% observed that providers did not demonstrate compassion or empathy, while 59.6% perceived low provider motivation or dissatisfaction with their work environment.

Workload and staffing emerged as prominent challenges, with 68.1% of mothers reporting that high workloads or staff shortages negatively affected care. Similarly, 55.3% indicated that providers did not receive regular updates or ongoing training on patient rights and respectful care, and 61.7% felt that providers were unapproachable or unwilling to listen to concerns. Alarmingly, 66% of mothers observed signs of provider burnout or fatigue during labor and delivery.

Factors associated with mistreatment during childbirth

Both bivariable and multivariable logistic regression analyses illuminated a constellation of maternal, provider, and facility-level determinants that powerfully shaped mistreatment during childbirth. After rigorous adjustment for confounders, nine variables like maternal education, perceived provider job satisfaction, salary adequacy, provider knowledge of respectful maternity care (RMC), compassion and empathy, provider approachability, observed burnout, staffing adequacy, and provider workload retained independent statistical significance, underscoring the multidimensional drivers of disrespectful care.

Maternal education emerged as a dominant social gradient. Women who could not read or write faced more than sevenfold higher odds of mistreatment compared with women who had college education or higher (AOR = 7.10, 95% CI: 3.71–13.58, p < 0.001). Similarly, Provider workplace perceptions exerted a pronounced influence. Low perceived provider job satisfaction more than doubled the likelihood of mistreatment (AOR = 2.05, 95% CI: 1.31–3.20, p < 0.001), signaling the behavioral consequences of demoralized staff. Likewise, perceived inadequate salary increase the odds by 59% (AOR = 1.59, 95% CI: 1.04–2.43, p = 0.020), while inadequate provider knowledge of respectful maternity care (RMC) elevated the risk by about 74% (AOR = 1.74, 95% CI: 1.10–2.75, p = 0.018). Together, these findings expose critical motivational and competency gaps within the maternity workforce.

Interpersonal care dynamics surfaced as potent behavioral drivers. Absence of compassion and empathy nearly tripled the odds of mistreatment (AOR = 2.95, 95% CI: 1.95–4.45, p < 0.001), sharply highlighting the centrality of humane care. Similarly, unapproachable providers doubled the likelihood of mistreatment (AOR = 2.05, 95% CI: 1.35–3.10, p < 0.001).

Workforce strain indicators demonstrated the most striking effects. Observed provider burnout or fatigue more than tripled the odds of mistreatment (AOR = 3.30, 95% CI: 2.14–5.10, p < 0.001), marking it as the strongest predictor in the model. Perceived inadequate staffing more than doubled the risk (AOR = 2.21, 95% CI: 1.49–3.29, p < 0.001), while high provider workload nearly tripled the likelihood (AOR = 2.70, 95% CI: 1.80–4.06, p < 0.001) (Table 4).

Table 4.

Logistic regression analysis of factors associated with mistreatment during childbirth among laboring mothers at public health facilities in ilubabor zone, Oromia Region, Southwest Ethiopia, 2025 (n = 470)

Variable	Category	Yes (Mistreatment) n (%)	No (Not Mistreated) n (%)	COR (95% CI)	AOR (95% CI)	p-value
Maternal Education Level	Can’t read & write	122 (81.9)	27 (18.1)	7.55 (4.01–14.22)	7.10 (3.71–13.58)	< 0.001*
	Primary school	86 (55.5)	69 (44.5)	3.23 (1.74–6.02)	3.08 (1.63–5.83)	0.010*
	Secondary school	50 (41.0)	72 (59.0)	1.91 (0.94–3.91)	1.95 (0.96–3.97)	0.070
	College + (ref)	11 (25.0)	33 (75.0)	Reference	Reference	–
Perceived Provider Job Satisfaction	Low	139 (76.4)	43 (23.6)	2.24 (1.44–3.48)	2.05 (1.31–3.20)	< 0.001*
	High (ref)	181 (62.8)	107 (37.2)	Reference	Reference	–
Provider Salary Adequacy	Inadequate	181 (66.5)	91 (33.5)	1.67 (1.11–2.51)	1.59 (1.04–2.43)	0.020*
	Adequate (ref)	139 (70.9)	59 (29.1)	Reference	Reference	–
Perceived Provider Knowledge of RMC	Inadequate	212 (65.0)	114 (35.0)	1.78 (1.15–2.76)	1.74 (1.10–2.75)	0.018*
	Adequate (ref)	108 (59.3)	74 (40.7)	Reference	Reference	–
Demonstration of Compassion & Empathy	No	197 (73.8)	70 (26.2)	2.99 (2.01–4.45)	2.95 (1.95–4.45)	< 0.001*
	Yes (ref)	123 (60.6)	80 (39.4)	Reference	Reference	–
Provider Approachability	No	179 (67.5)	86 (32.5)	2.09 (1.39–3.13)	2.05 (1.35–3.10)	< 0.001*
	Yes (ref)	141 (68.4)	64 (31.6)	Reference	Reference	–
Observed Provider Burnout/Fatigue	Yes	187 (73.6)	67 (26.4)	3.47 (2.28–5.27)	3.30 (2.14–5.10)	< 0.001*
	No (ref)	133 (61.6)	83 (38.4)	Reference	Reference	–
Staffing Adequacy Perceived	Inadequate	178 (63.6)	102 (36.4)	2.34 (1.59–3.43)	2.21 (1.49–3.29)	< 0.001*
	Adequate (ref)	142 (74.7)	48 (25.3)	Reference	Reference	–
Provider Workload	High	171 (66.8)	85 (33.2)	2.80 (1.89–4.17)	2.70 (1.80–4.06)	< 0.001*
	Low (ref)	149 (69.0)	65 (31.0)	Reference	Reference	–

Nagelkerke R² = 0.284 (the model explains 28.4% of the variance in mistreatment). COR = Crude Odds Ratio; AOR = Adjusted Odds Ratio [95% CI for AORs are reported only for the adjusted model]; CI= confidence interval, *p < 0.05; ref = reference category

Discussion

In this study, the prevalence of mistreatment during childbirth among laboring mothers in Ilubabor Zone reached 68.1% (95% CI: 63.9–72.3%). This substantial burden exceeds the global pooled estimate of 54.5% by 13.6% points and surpasses sub-Saharan African pooled estimates of 44–47% by 21–24% points [13, 26–29]. This could be due to persistent systemic pressures including chronic understaffing, overcrowding, and sociocultural norms that tolerate gender-based inequities. It markedly exceeds rates documented in high-income settings, where mistreatment typically ranges from 13.4% to 20% in the United States [30] and 13.5% to 30.2% across European countries [31], reflecting stronger regulatory oversight, better staffing ratios, and more robust accountability mechanisms in resource-rich environments. In Ethiopia, the finding aligns closely with or slightly surpasses facility-based reports from other regions, including 67.1% in Bahir Dar [18], 74.8% in Western Ethiopia [19], and up to 77% to 87.4% in eastern and central zones [32, 33], highlighting pronounced rural-urban and zonal disparities where infrastructure limitations and provider strain are associated with higher mistreatment.

These lower prevalence in high-income and certain middle-income contexts can be attributed to several structural advantages: well-resourced facilities with lower patient-to-provider ratios reduce provider burnout and time pressure, enabling more patient-centered care; stringent legal and ethical frameworks enforce accountability and patient rights; widespread implementation of respectful maternity care training and monitoring protocols; and greater cultural emphasis on gender equity and informed consent, which collectively minimize opportunities for abuse or neglect.

The elevated prevalence in Ilubabor is associated with rural-urban disparities common in Ethiopia and sub-Saharan Africa, where isolated zones experience higher mistreatment linked to geographic barriers. Longer travel times (21.5% >60 min) and limited transportation constrain access, concentrating caseloads in facilities and increasing provider pressure, time scarcity, and frustration that may be associated with mistreatment. Rural facilities often have more acute staffing shortages, lower salaries, and reduced budgets compared to urban hospitals, amplifying strain and reducing time for respectful care. The dominance of interpersonal forms such as verbal insults and refusal of pain relief over physical abuse suggests a pattern of systemic normalization rather than isolated malice, potentially exacerbated by cultural tensions between traditional birthing expectations and institutional protocols prevalent in Oromia [34]. These contextual dynamics illustrate how geographic marginalization and socioeconomic disadvantage sustain mistreatment as a structural barrier, undermining trust in healthcare and contributing to suboptimal utilization of services despite national improvements in institutional delivery rates [35].

Maternal education emerged as a dominant social gradient. Women who could not read or write faced nearly sevenfold elevated odds of mistreatment compared with women who had college education or higher. Although primary and secondary education showed increased odds, these effects failed to sustain statistical significance after adjustment, suggesting that the burden of mistreatment concentrates most intensely among the least educated women. This pattern is consistent with findings from low- and middle-income countries worldwide, including pooled data from sub-Saharan Africa and South Asia, where uneducated women consistently face the highest risk [26, 36]. This could be explained as lies in power imbalances: less-educated women often lack the confidence and knowledge to assert their rights or question providers, making them more vulnerable to dismissive or coercive treatment. In rural Ethiopian settings like Ilubabor, this vulnerability is amplified by overlapping poverty and cultural norms that discourage women from challenging authority, creating a deeper disparity than observed in more educated urban or high-income populations where patient advocacy is stronger. Generally, these findings underscore the need for community-based empowerment and health literacy interventions that inform women of their rights during childbirth, as recommended in the policy implications section.

Provider workplace perceptions exerted a pronounced influence. Low perceived provider job satisfaction almost tripled the likelihood of mistreatment, signaling the behavioral consequences of demoralized staff. This finding mirrors results from multiple sub-Saharan African studies and parts of South Asia, where provider dissatisfaction is repeatedly linked to disrespectful care [37, 38]. The possible reason is that demoralized staff, facing chronic stress and poor working conditions, displace frustration onto patients through verbal abuse or neglect, a pattern less evident in high-income settings where better support systems buffer against such spillover.

Likewise, perceived inadequate salary amplified the risk. Similar associations have been reported across low-resource African and Asian contexts, but the effect is typically weaker in high-income countries where salaries are higher and more equitable [39]. The explanation appears to be economic frustration: when providers feel inadequately compensated, resentment builds and manifests as reduced patience and poorer interpersonal care, particularly in isolated rural facilities where alternative income sources are limited.

Inadequate provider knowledge of respectful maternity care escalated the risk. This is consistent with findings from Ethiopia, Kenya, and India, where gaps in RMC training correlate strongly with mistreatment [40, 41]. The might be due to is straightforward: without specific training on dignity and rights, providers fall back on hierarchical or task-oriented behaviors that patients experience as disrespectful.

Interpersonal care dynamics surfaced as potent behavioral drivers. Absence of compassion and empathy nearly tripled the odds of mistreatment, sharply highlighting the centrality of humane care. Unapproachable providers doubled the likelihood of mistreatment. Both patterns align with qualitative evidence from sub-Saharan Africa and Latin America, where lack of empathy and poor communication are among the most frequently reported forms of mistreatment [28, 42]. The occurrence lies in the emotional labour of maternity care: when providers are exhausted or untrained in relational skills, they withdraw emotionally, which patients interpret as coldness or disrespect, an effect magnified in high-pressure rural environments.

Interestingly, mothers who perceived staffing as adequate reported a higher prevalence of mistreatment (74.7%) compared to those who perceived inadequate staffing (63.6%). This counterintuitive, perception-driven pattern may reflect that women in better-staffed facilities have higher expectations of care quality and are therefore more likely to perceive and report disrespectful treatment. In contrast, women in highly understaffed facilities may lower their expectations and normalize poor care.

Workforce strain indicators demonstrated the most striking effects in the multivariable analysis. Observed provider burnout or fatigue was the strongest predictor of mistreatment (AOR = 3.30, 95% CI: 2.14–5.10), highlighting the critical role of provider well-being in delivering respectful maternity care. This finding aligns with the broader reality of chronic understaffing in rural Ethiopian health facilities. Despite the high prevalence of mistreatment (68.1%), a substantial proportion of mothers (74.5%) indicated that their experience would encourage them to utilize facility-based delivery in the future. This apparent paradox can be framed as a risk–perception trade-off, whereby women weigh the fear of life-threatening obstetric complications against the fear of mistreatment. In rural Ilubabor Zone, the perceived safety and presence of skilled birth attendants appear to outweigh concerns about disrespectful care, as women have limited acceptable alternatives to facility-based delivery. This finding is consistent with qualitative and mixed-methods studies in rural Ethiopia and other low- and middle-income settings, where the desire for better clinical outcomes often takes precedence over poor interpersonal aspects of care when choices are constrained by geographic and socioeconomic realities [29, 43, 44].

The possible interpretation is that exhausted and overstretched providers have reduced emotional reserves and time, leading to shortcuts, irritability, and neglect that women experience as mistreatment. In contrast, high-income settings with better staffing ratios show much weaker associations between workload and disrespectful care.

Strengths and limitations

This study offers several key strengths. It provides timely, context-specific evidence from a rural, underrepresented zone in Southwest Ethiopia using a facility-based design that captured real-time experiences with a high response rate of 98.1%. The culturally adapted questionnaire grounded in the WHO mistreatment typology and the inclusion of provider-perceived factors extend beyond many previous studies, offering actionable insights aligned with Ethiopia’s Compassionate, Respectful, and Caring initiative and global Sustainable Development Goals.

Despite these strengths, some limitations must be acknowledged. First, the cross-sectional design precludes establishing causality between the identified factors and mistreatment during childbirth. Second, provider-related factors such as burnout, workload, and salary adequacy were assessed through maternal perceptions rather than direct provider reports; future studies should incorporate provider surveys for better triangulation. Third, although interviews were conducted in private settings by external midwives within 24 h postpartum, recall and social desirability biases cannot be entirely ruled out. Fourth, the few non-respondents (mainly due to severe postpartum fatigue or medical conditions) may have led to a slight underestimation of mistreatment prevalence if women with the most negative experiences were less likely to participate. Finally, as this was a facility-based study, it does not capture experiences of women who delivered at home (approximately 36% of deliveries nationally). The population-level burden of mistreatment could therefore be higher or lower depending on practices by traditional birth attendants. However, findings are primarily generalizable to public health facilities in Ilubabor Zone and align closely with national and regional patterns in Ethiopia.

Conclusion

This study reveals a high prevalence of mistreatment during childbirth in Ilubabor Zone (68.1%, 95% CI: 63.9–72.3%), associated primarily with low maternal education, low provider job satisfaction, inadequate salaries, inadequate knowledge of respectful maternity care (RMC), lack of compassion and empathy, poor approachability, observed burnout, inadequate staffing, and high workload.

Recommendations

• Federal Ministry of Health: Use these findings to inform the development of the next Health Sector Transformation Plan (beyond 2024/25) and integrate mandatory RMC training with strengthened monitoring within annual performance frameworks, particularly in rural Oromia zones like Ilubabor.

• Regional Health Bureaus: Prioritize rural staffing incentives (e.g., salary supplements, housing allowances) and workload redistribution to reduce burnout and improve provider satisfaction in remote zones like Ilubabor. Initiate mobile maternal units for remote areas and incentives for rural postings.

• Health Facilities: Implement facility-level audits for respectful maternity care, including patient feedback mechanisms, companion policies during labor, and regular burnout screening/support for staff.

• Community and Traditional Leaders: Collaborate with health extension workers to conduct community education campaigns on women’s rights during childbirth and the benefits of facility-based delivery, addressing cultural barriers and promoting birth companionship.

• Research and Policy Actors: Support longitudinal and mixed-methods studies to evaluate the impact of RMC interventions and explore provider perspectives in rural settings, informing evidence-based policy updates under the Compassionate, Respectful, and Caring (CRC) initiative.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Abbreviations

ANC

Antenatal Care

BEmONC

Basic Emergency Obstetric and Newborn Care

CEmONC

Comprehensive Emergency Obstetric and Newborn Care

CRC

Compassionate, Respectful, and Caring

D&A

Disrespectful and Abusive Care

DMC

Disrespectful Maternity Care

ETB

Ethiopian Birr

IRB

Institutional Review Board

LMICs

Low- and Middle-Income Countries

MMR

Maternal Mortality Ratio

PNC

Postnatal Care

RMNCH

Reproductive, Maternal, Newborn, and Child Health

SBA

Skilled Birth Attendant

SDG

Sustainable Development Goal

SPSS

Statistical Package for the Social Sciences

WHO

World Health Organization

Author contributions

ETB conceptualized the study, led data collection and analysis, and drafted the manuscript. TET, AKS, and AFT contributed to design, data interpretation, and critical revision. All authors read and approved the final manuscript.

Funding

This research was supported by a grant from Mattu University. The funder had no role in the study design, data collection, analysis, interpretation, or manuscript preparation, ensuring the independence of the research process.

Data availability

De-identified datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Institutional Review Board (IRB) of Mattu University, College of Health Sciences, Department of Midwifery (Ref: MDD/553/2025). Written informed consent was secured from all participants aged 18 years and older. For participants under 18 years, parental or guardian consent was obtained, with assent from the minor, documented by the interviewer in the presence of an independent witness to verify understanding and agreement. Data were anonymized using unique identifiers, stored securely on password-protected systems, and accessible only to the research team. No incentives were provided to participants to avoid coercion, in line with ethical guidelines for research in low-resource settings and the Declaration of Helsinki. Participants were informed of their right to withdraw at any time without consequences. Findings will be disseminated to local health authorities to inform policy and enhance maternity care practices in Ilubabor Zone.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.