Table 3. Summary of qualitative findings.
| Review Finding | Contributing Studies | Confidence in the Evidence | Explanation of Confidence in the Evidence Assessment |
|---|---|---|---|
| Physical abuse | |||
| Use of force: Women across the world reported experiencing physical force by health providers during childbirth. In some cases, women reported specific acts of violence committed against them during childbirth, but women often referred to these experiences in a general sense and alluded to beatings, aggression, physical abuse, a rough touch, and use of extreme force. Pinching, hitting, and slapping, either with an open hand or an instrument, were the most commonly reported specific acts of physical violence. | [6,9,10,13,21,61,67,68,73,75,77,80,84,86,87,91,96,97] | High | 18 studies with minor to significant methodological limitations. Thick data from 11 countries across all geographical regions, but predominantly sub-Saharan Africa. High coherence. |
| Physical restraint: Women in Tanzania and Brazil reported physical restraint during childbirth through the use of bed restraints and mouth gags. | [86,97] | Low | 2 studies with minor to significant methodological limitations. Limited, thin data from 2 countries (Tanzania and Brazil). Extent of coherence unclear due to limited data. |
| Verbal abuse | |||
| Harsh or rude language: Across high-, middle-, and low-income countries, verbal abuse of women by health providers during childbirth was a commonly reported event, particularly the use of harsh or rude language. Women’s perceptions of their facility-based childbirth experiences were often shaped by negative encounters with health workers in which they were verbally abused. | [6,7,9,10,13,48,51–55,58,59,61,63,64,67,68,70,73,75,77,80,81,83,85,87,88,90,91,93] | High | 31 studies with minor to significant methodological limitations. Thick data from 18 countries across all geographical regions, but predominantly sub-Saharan Africa. High coherence. |
| Judgmental or accusatory comments: Women reported feeling shamed by health workers who made inappropriate comments to them regarding their sexual activity. Insensitive comments may be experienced more frequently by adolescent or unmarried women, since many communities view pregnancy and childbirth as appropriate only in the context of marital relationships. Intentionally lewd comments humiliated the women while they were in an already vulnerable position during childbirth and in need of supportive care. As a result, women often felt that their health provider was disrespectful, uncaring, and rude. | [10,13,55,58,59,73,77,80,87,91] | Moderate | 10 studies with minor to significant methodological limitations. Fairly thick data from 8 countries, predominantly low-income countries. High coherence. |
| Threats and blaming: Some women were threatened with poor quality of care or poor outcomes for their babies as a result of their behavior during childbirth. This included threats of a beating if the woman did not comply with a health worker’s request and threats of withholding health services. Other women were blamed for their baby’s or their own poor health outcomes. | [13,58,59,63,68,77] | Moderate | 6 studies with minor to significant methodological limitations. Adequate data from 5 countries, predominantly middle- and high-income countries. High coherence. |
| Stigma and discrimination | |||
| Discrimination based on ethnicity/race/religion: Women commonly reported feeling discriminated against due to their ethnic or racial backgrounds. Differential treatment by health workers often pervaded their experiences during childbirth and influenced the quality of care they received. This type of treatment tended to make women feel alienated from their health care providers. In some settings, migrants and refugees received particularly disrespectful care and may have been expected to pay higher rates for services or to pay bribes. This included Somali women with female genital cutting in Canada, Roma women in the Balkans, and refugee women in South Africa. | [8,13,49,52,53,58,62,63,67,72,78,80,95] | High | 13 studies with minor to significant methodological limitations. Thick data from 10 countries across all geographical regions and country income levels. High coherence. |
| Discrimination based on age: Women believed that they were discriminated against based on their age, for being pregnant either as an unmarried adolescent or as an older woman of high parity. Adolescents were criticized and ridiculed for engaging in sexual activity before marriage, and some felt that their confidentiality was breached due to their age. Adolescents in South Africa reported that mistreatment that they or their friends experienced during facility-based childbirth directly influenced them to deliver at home in the future. | [9,55,63,67,77,80,88] | Moderate | 7 studies with minor to significant methodological limitations. Fairly thick data from 5 countries, but particularly in South Africa. High coherence. |
| Discrimination based on socioeconomic status: Across the world, women who were of lower socioeconomic status reported feeling discriminated against due to their social class or income level. They believed that they received poorer treatment or were neglected because they were poor and often unable to pay for services or to pay bribes. They often felt that health workers humiliated them for their poverty, for their inability to read or write, or for residing in rural or slum areas. Fear of such discrimination was considered a powerful disincentive to deliver in health facilities in Ghana, Sierra Leone, and Tanzania. | [8–10,58,62,67,75,76,79,90,91,93] | High | 12 studies with minor to significant methodological limitations. Thick data from 13 countries (1 multi-country study), but predominantly in sub-Saharan Africa. High coherence. |
| Discrimination based on medical conditions: Some women in Kenya and South Africa believed that their positive HIV status contributed to the provision of substandard care, including delays in receiving essential interventions, avoidance of patient contact, and fewer vaginal examinations. However, some health workers in Kenya stated that there was no discrimination against or segregation of HIV-positive women in the labor ward, although they reported being “anxious” if they suspected a woman was HIV-positive and might have handled such women with “extra care.” | [11,13,27] | Low | 3 studies with minor to significant methodological limitations. Adequate data from 3 countries (South Africa, Kenya, and Tanzania). Reasonable level of coherence; the finding may have higher confidence in settings with similar HIV epidemics or where there may be discrimination based on other medical conditions. |
| Failure to meet professional standards of care | |||
| Painful vaginal exams: Some women reported frequent and painful vaginal examinations during labor. They viewed the number of vaginal examinations they received during labor as excessive and dehumanizing. In some cases, vaginal examinations were conducted in non-private settings and women may not have consented to the procedure, or the procedure may not have been communicated to them. | [54,58,74,80,83,86,89,95] | Moderate | 8 studies with minor to significant methodological limitations. Fairly thick data from 5 countries across multiple geographical regions and country income levels. High coherence. |
| Refusal to provide pain relief: Across multiple settings, women described health workers’ refusal to provide pain relief or pain medication not being available for them during labor. Surgical procedures, such as episiotomy, were sometimes carried out without any pain relief. In lower-resource settings, this was often due to stock outs or lack of sufficient patient payment. In higher-resource settings, women reported that they were not offered pain relief or were denied pain relief requested. | [13,21,58,68,75,77,80,81,90,92,93] | High | 11 studies with minor to moderate methodological limitations. Thick data from 9 countries across multiple geographical regions and country income levels. High coherence. |
| Lack of informed consent process: Women complained that they were not always asked to provide consent for medical procedures such as cesarean section. When women were asked to provide consent prior to a procedure, they were not always adequately informed of the risks and benefits of the procedure and felt that the health worker went through the motions of obtaining consent. Some women in Kenya also avoided or feared facility-based delivery due to anxiety about being tested for HIV without their consent. | [11,13,92] | Moderate | 3 studies with minor to moderate methodological limitations. Fairly thick data from 3 countries (Kenya, South Africa, and United Kingdom). High coherence. |
| Breaches of confidentiality: Some women complained that the health workers did not maintain doctor–patient confidentiality and disclosed private information either to their male partners or to other patients. For some HIV-positive women in Kenya, the lack of trust in the confidentiality of treatment at health facilities was so great that they chose to deliver at home, where their HIV status would not be disclosed to other community members or health workers. | [11,13,27,55,59] | Moderate | 5 studies with minor to significant methodological limitations. Fairly thick data from 5 countries, particularly in sub-Saharan Africa. High coherence. |
| Neglect, abandonment, or long delays: Women frequently referred to long delays in receiving care and inattentive health workers who neglected women during labor and delivery. Women commonly reported feeling alone, ignored, or abandoned during their stay at the facility, and felt as if their request for help or attention from health workers was an imposition. Many women reported long wait times before seeing a health worker or before receiving an intervention. Long wait times may have been exacerbated when women did not book prior to delivery, as their information may not have been in the system, and they perceived that health workers punished women who did not book ahead with longer wait times. These experiences of neglect and abandonment by health workers in facilities were direct barriers to seeking future deliveries in facilities in Ghana, Bolivia, and Tanzania, as some women prioritized the need for supportive childbirth care, which they could receive from traditional providers. | [6–10,13,21,48,51,59,62–64,66–68,70,71,75–78,80,81,84,86–88,92–95,97] | High | 33 studies with minor to significant methodological limitations. Thick data from 21 countries across all geographical and country income levels. High coherence. |
| Skilled attendant absent at time of delivery: Some women reported that health worker shortages and negligence directly increased the physical risks women faced during delivery. In some extreme cases of neglect, women delivered at facilities without the presence of skilled birth attendants, who were preoccupied with other tasks. | [9,13,21,48,59,67,77,81,84,86,87,93] | High | 12 studies with minor to significant methodological limitations. Thick data from 8 countries, particularly in the Middle East and sub-Saharan Africa. High coherence. |
| Poor rapport between women and providers | |||
| Poor communication: Women commonly referred to communication issues between health workers and themselves that left women feeling “in the dark” about their childbirth care. Many women felt dissatisfied with the information and explanations provided to them by health workers regarding their care and believed that the health workers were more interested in having them comply with their demands than in allowing the women to ask questions to clarify the proposed procedures. These experiences made women feel distanced from health workers, fearful of procedures, and like they were not active participants in their childbirth experience. Some women in the United Kingdom, Dominican Republic, and Brazil reported believing that health workers intentionally avoided exchanging information with patients and described health workers as unresponsive to patient needs. | [6,8,11,13,21,48,50,52,53,57,58,60,62,64,66,67,70,73,75,78,84,86,88,92–94,96,97] | High | 28 studies with minor to significant methodological limitations. Thick data from 22 countries across all geographical regions. High coherence. |
| Language and interpretation issues: Women often suffered from language and interpretation barriers when attempting to communicate with health workers, and this was particularly a burden for migrant and refugee women in high-income settings. | [8,13,52,58,62,78] | Moderate | 6 studies with minor to moderate methodological limitations. Fairly thick data from 6 middle- and high-income countries. High coherence. |
| Lack of supportive care from health workers: Women commonly reported a lack of supportive care during childbirth in facilities, including the perception that the care provided by health workers was mechanical and lacked comfort and courtesy. During their deliveries, women often felt that they did not receive the time and attention from health workers to make them feel supported and adequately cared for. Women felt that staff were insensitive to their needs, which made women feel unconfident, anxious, and alone. Many women believed that delivering in a health facility would ensure positive health outcomes for themselves and their babies. However, while they often felt that they received technically sound care, their experiences at the facility were marred by feelings of being emotionally unsupported. Women felt that they were provided with systemized, mechanistic care that focused solely on technical outcomes rather than supportive care that incorporated sensitive communication and a comforting touch. Women from Sierra Leone, Uganda, and rural China stated that when expectations of a supportive environment during a facility-based childbirth were not met, they may be less inclined to deliver at a facility in future births. | [6,7,9,21,48–50,52,57,58,60,61,63,65,66,71–73,75,78,81,82,88,90,92,93] | High | 26 studies with minor to significant methodological limitations. Thick data from 21 countries across all geographical regions, but predominantly in sub-Saharan Africa. High coherence, but lack of supportive care in lower-income settings may impact future childbirth care-seeking behaviors. |
| Denial or lack of birth companions: Women desired the supportive attention and presence of a birth companion, who may be a family member, husband, or a friend. However, women across the world were often prohibited from having a companion of their choice during delivery. Although not always clearly explained to clients, it was often official hospital policy to ban birth companions, as they were deemed unnecessary by the administration. The lack of companionship left women feeling disempowered, frightened, and alone during childbirth as they yearned for the comfort provided by familiar faces. | [6,9,21,48–50,54,66,72,75,78,90] | Moderate | 12 studies with minor to significant methodological limitations. Fairly thick data from 9 countries across many regions, but predominantly middle-income settings. High coherence. |
| Lack of respect for women’s preferred birth positions: Some women preferred to deliver in positions other than the supine position, such as by squatting or kneeling, and resented that health workers forced them to deliver in undesirable or humiliating positions. Women felt that adopting an undesirable birth position at the demand of the health worker made them passive participants in their childbirth process. Restricting the childbirth position to lying down acted as a barrier for some women to access facility-based deliveries in Bangladesh. Health workers in Bangladesh, Cuba, and Uganda explained that they had not been trained to deliver women in positions other than lying down and felt uncomfortable letting a woman choose her own birth position. | [6,9,21,53,70,72,82,89] | Moderate | 8 studies with minor to significant methodological limitations. Adequate data from 7 countries, predominantly middle-income countries. Reasonable level of coherence. |
| Denial of safe traditional practices: Some women in Ghana and the United Kingdom referred to the denial of safe traditional religious or cultural practices related to childbirth. Maintaining these traditional practices, such as retaining the placenta for burial, were important to women, and the denial of these practices may be an important barrier to seeking facility-based delivery or experiencing quality supportive care. | [10,78] | Low | 2 studies with minor to moderate methodological limitations. Fairly thin data from 2 counties (United Kingdom and Ghana). Extent of coherence unclear due to limited data, but findings were similar across the studies. |
| Objectification of women: In several settings, women reported feeling stripped of their dignity during childbirth due to the health workers’ objectification of their bodies. They resented being forced to be on all fours and exposing their bodies to numerous health workers, sometimes including large groups of students. | [13,21,48,57,84] | Moderate | 5 studies with minor to significant methodological limitations. Adequate data from 8 countries (1 multi-country study), but only in middle- and high-income settings. Reasonable level of coherence for middle- and high-income settings. |
| Detainment in facilities: Studies from Benin and Sierra Leone suggest that either the mother or baby may be detained in the health facility, unable to leave until they pay the hospital bills. | [73,90] | Low | 2 studies with moderate methodological limitations. Fairly thin data from 2 countries (Benin and Sierra Leone). Extent of coherence unclear due to limited data, but findings were similar across the studies. |
| Health systems conditions and constraints | |||
| Physical condition of facilities: Both women and health workers described the physical conditions of health facilities that contributed to the mistreatment of women. Antenatal and delivery wards were described as “dirty,” “noisy,” “disorderly,” or “overcrowded,” or with needles, biomedical waste, or dirt strewn on the floor. | [27,53,59,67,70,84,95,96] | Moderate | 8 studies with minor to significant methodological limitations. Fairly thick data from 8 low- and middle-income countries. High coherence. |
| Staffing shortages: Both women and health workers illustrated how staffing shortages affected the quality of care provided. Staffing shortages were of particular concern in low- and middle-income countries and often led to longer wait times for women and their families, as well as neglectful or poor-quality care. Women and health workers both purported that staffing shortages not only affected direct provision of care but also contributed to the health workers’ negative attitudes or lack of motivation. In low- and middle-income countries, providers of all cadres were described as “overworked,” “too busy,” “stretched,” and “underpaid” by both women and other providers. | [13,51,78,84,87,90,91,93] | Moderate | 8 studies with minor to significant methodological limitations. Fairly thick data from 7 countries, particularly in sub-Saharan Africa. High coherence. |
| Staffing constraints: In addition to the understaffing of health workers, inexperienced or poorly trained health workers were often responsible for inappropriate levels of care without supportive supervision. In lower-level facilities, qualified physicians may be a rarity, leaving unskilled nurses to attend to labor management, complications, and decisions regarding referrals. | [53,54,84,86, 87,96] | Low | 6 studies with minor to significant methodological limitations. Adequate data from 6 countries. High coherence. |
| Supply constraints: Health workers and male partners explained that there were often inadequate medical supplies, including medication, gloves, and blood, which are critical for health workers to execute their duties. In some cases, this shortage led to the requirement that patients bring their own supplies, such as gloves, gauze, and pads. This may have caused health workers to attend first to women who brought their own supplies, or for women to think that the health workers were withholding supplies from them for malicious reasons. Health workers believed that the shortage of supplies, particularly gloves, caused unnecessary danger and stress in the work environment. | [9,27,54,61,67,70,87,93,96] | Moderate | 9 studies with minor to significant methodological limitations. Thick data from 7 low- and middle-income countries. High coherence for low- and middle-income settings. |
| Lack of privacy: Women across many settings reported a general lack of privacy in the antenatal and labor wards and specifically during vaginal and abdominal exams. Women were exposed to other patients, their families, and health workers due to the lack of curtains to separate them from other patients, the lack of curtains on the outside windows, and doors that were left open. In low- and middle-income countries, the antenatal and labor/delivery wards were sometimes common or public areas, and women were sometimes forced to share beds with other parturient women who may be strangers. Not surprisingly, women expressed their desire to be shielded from other patients, male visitors, and staff who were not attending them while they were in labor and particularly during physical exams. They felt that such exposure, particularly during this vulnerable time, was undignified, inhumane, and shameful. | [11,21,49,53,54,58,70,74,75,84,95,96] | High | 12 studies with minor to significant methodological limitations. Thick data from 11 countries across all geographical and income-level settings. High coherence. |
| Lack of redress: Women lamented the inability to express their opinions about the treatment and services rendered during childbirth. Several reasons for this were posited, including women fearing unfair treatment or discrimination if they complained, women being unaware of their rights as patients, fear of facility closure, and a lack of a redress or accountability mechanism for lodging complaints. Even in settings where health policies dictated the creation of a formal complaint registration system, these systems may not have been implemented at a facility level. The lack of accountability and sanctioning within the health system left women feeling vulnerable and powerless to seek justice for their mistreatment. | [8,9,13,67,77] | Moderate | 5 studies with minor to significant methodological limitations. Adequate data from 4 countries (1 multi-country study), but 3 studies are from South Africa. Reasonable level of coherence. |
| Bribery and extortion: In several settings, women reported the need to pay bribes to different workers throughout health facilities, including to doctors, nurses, midwives, receptionists, and guards. Bribes took the form of money, food, drinks, or other gifts. Women believed that paying bribes positively influenced the quality of services provided to them in health facilities. For instance, bribery could ensure that women received timely care, adequate attention from health providers, and any necessary drugs or medications. Health workers were perceived to ignore women in the maternity ward until the patients paid the bribe, at which point, the health workers would become attentive to their needs. One study from the Balkans explicitly stated that Roma women avoided facility-based deliveries because they know that bribes are required to receive sufficient care. | [8,9,13,56,71,75,76,93] | Moderate | 8 studies with minor to significant methodological limitations. Fairly thick data from 8 countries, but predominantly in sub-Saharan Africa. Reasonable level of coherence. |
| Unclear fee structures: Women in Tanzania reported that an unclear fee structure for services and supplies rendered during childbirth led to frustration, confusion, and a fear of detainment in the facility. | [9] | Low | 1 study with minor methodological limitations. Fairly thick data, but only from Tanzania. Coherence could not be assessed as only 1 contributing study. |
| Unreasonable requests of women by health workers: In South Africa and Ghana, women were angry at health workers for making unreasonable demands of them during their stay at health facilities. In particular, women were forced to clean up the “mess” they made on the floor or bed immediately after both vaginal deliveries and cesarean sections, when women were feeling particularly weak and vulnerable. Some women were told to walk to a different room, to retrieve supplies or to dispose of medical waste during the second stage of labor or immediately after delivery, without a wheelchair or support from birth attendants. | [6,7,13,67,77] | Moderate | 5 studies with minor to significant methodological limitations. Fairly thick data from 2 countries (South Africa and Ghana). High coherence. |
| Impact on utilization of maternal health services | |||
| Power dynamics and systemized abuse: Health workers discussed how the hierarchical authority in the health system legitimized the control that health workers have over their patients and contributed to the detrimental treatment of women during childbirth. These power differentials place women at the bottom of the hierarchy, where their needs and concerns were often ignored or deemed as unimportant by health workers. Furthermore, the lack of supportive supervision for health workers from their superiors contributed to feelings of demoralization and negative attitudes, thus perpetuating the mistreatment of women. As a result of past negative experiences, both health workers and patients may have come to expect and accept the poor treatment of women as the norm. | [10,13,59,77,91] | Moderate | 5 studies with minor to significant methodological limitations. Fairly thick data from 4 low- and middle-income countries. High coherence. |
| Impact on future care-seeking behaviors, late attendance to facilities, and desire for home birth: Experiences of mistreatment during childbirth may have far reaching consequences for women and communities outside of the direct patient–provider interaction. Prior experiences and perceptions of mistreatment, low expectations of care provided at facilities, and poor reputations of facilities in the community eroded many women’s trust in the health system and may impact their decision to deliver in a health facility in the future, particularly in low- and middle-income countries. | [6,8–10,13,21,52,53,61,64,71,77–79,82,85,90,94,96] | High | 19 studies with minor to significant methodological limitations. Thick data from 16 countries, but particularly in low- and middle-income countries and sub-Saharan Africa. High coherence. |
A summary of the review findings from the qualitative synthesis are presented here, with the relevant studies contributing to each review finding. The confidence in the evidence refers to the overall CERQual assessment of the methodological limitations of included studies, relevance, adequacy, and coherence, and is rated as high, moderate, or low. The explanation of the assessment of the confidence in the evidence provides a brief assessment of each CERQual domain to support the overall CERQual assessment.