Table 2.

Manifestations of mistreatment of women during childbirth in Kenya

Third order themes	Second order themes	Illustrative manifestations of experiences and reports of first order themes from Kenya
		Women	Men	Health providers (HPs)/managers
Intentional mistreatment: use of violence, physical, verbal, negligent withholding of care
Physical abuse	Use of force	Slapping/pinching	Beaten by HPs	Slap to save a woman’s life
	Physical restraint	Pushing my thighs	Helped to make the woman cooperate or obey	To make room for baby to come out if mother is closing legs. Fear of being reprimand for poor out pregnancy comes
Sexual abuse	Sexual abuse	Not recorded in any data from this study
Verbal abuse	Harsh language Threats and blaming	Insulting language; Threatening and insulting relatives/caretaker Women blamed for negative outcomes Reprimanding client if she calls for help	Insults from health providers to women and caregivers	Harsh words ‘helps’ women and relatives cooperate; You must appear tough to gain cooperation Personal attitude
Stigma and discrimination	Discrimination based on ethnicity, socioeconomic status	Women ‘blamed’ for high parity, age and socioeconomic status Tribalism/ethnicity	Devalues my partner/wife and I or my community	Women take too long to understand. HPs overworked, stereo typing, negative attitude and values ‘that tribe behavior/react like that”
		HIV positive women avoided or abandoned	Men forced to take HIV test	Fear, stigma lack of knowledge
Failure to meet professional standards of care	Lack of informed consent for physical exam and procedures	HPs discuss the examination results with others	Devalues my wife and I	Rooms do not offer audio privacy
		Student allowed to do episiotomy ‘badly’ Frequent vaginal examinations/multiple tests by HPs and students		Student must learn on clients: too many students must achieve skills in a short time. Lack of HPs skills and confidence.
	Lack of confidentiality and privacy	Examination, delivery and treatment required to undress without curtains or partitions	Bed sharing	Lack of curtains Too many clients Limited space
		Women have to give personal information in public (within hearing distance of others)		Over crowding
	Neglect and abandonment	Older/higher parity women report left to deliver on their own as HPs abandon them due to their previous birth experience	HPs refuse to help women in labor if not come with drugs, supplies, money. Men rush to buy them.	Too busy, overworked, uncooperative mother. Poor staff attitude, “have done my shift for the day”, lack of team work. Inadequate supervision, Demotivated.
		Ignoring clients’ calls for help	HPs not available or at night
		Doctor not available to conduct cesarean section	No doctor available	Absenteeism; report late on duty, no housing for doctors; lack of transport.
		HPs not responding to client when in pain	Some women too afraid of pain	Poor staff attitude; Lack of professional ethics; Poor leadership
Poor rapport between women and health providers	Lack of autonomy	Not involved in decision making in my care Used language that I could not understand Lack of food/drink. No bathing facilities		Poor staff attitude. Too busy to explain, they do not get even if you explained, Ineffective counseling/communication.
	Detainment	Lack of money makes mothers avoid going to hospital	Women are detained	Clients are abandoned by their relatives in hospital.
	Ineffective communication	Not given information about my care Do not understand the need for frequent vaginal examinations	Not consulted or informed about my wife’s progress or babies condition	HPs have no time to discuss procedures due to high workload Clients do not understand
Structural disrespect deviations
Health system conditions an constraints	Lack of resources	Lack of equipment. bed sharing, Lack of curtains/clean linen	Facility request money to buy drugs	Inadequate supplies, lack of funds, misuse of funds, lack of maintenance, poor planning and forecasting
		No water for bathing, dirty bathrooms No food
		No support staff Staff shortage/no supervision/poor leadership. Made to clean up	Have to buy the drugs and supplies	Shortages Staff and equipment and supplies
	Facility culture	Too few staff	Staff not supervised	Staff shortages Ineffective supervision
	Corruption/bribery	You must stretch your hand Some behave in a way that they want to be bribed	Pay bribe to get own bed	Poor and delayed pay. Accepted norm- everyone is doing it anyway

The illustrative manifestations (first-order themes describing specific events or instances of mistreatment) presented in this table are drawn from the study findings in Kenya. We have adapted these to the framework developed by Bohren et al [2] using a global evidence-based typology (third, second and first order themes) of mistreatment of women during childbirth. The second- and third-order themes classify first-order themes into meaningful groups based on common attributes. The third-order themes are ordered from the level of interpersonal relations through the level of the health system

HP health provider