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Background Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)–US study. Methods Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables. Results Of eligible participants ( n  = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment. Conclusion This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

Introduction Obstetric violence, or mistreatment of women in obstetric care, can have severe consequences such as fear of future childbirth, post‐traumatic stress disorder, and depression. Material and Methods The primary objective was to estimate the prevalence of obstetric violence in high‐income countries. The secondary objective was to extract the main domains of obstetric violence perceived by women from qualitative studies. Following prospective registration (PROSPERO CRD42023468570), PubMed, Web of Science, Scopus, CINAHL, Embase, and Cochrane Library were searched with no restrictions. Included studies were cross‐sectional, cohort, mixed methods, and qualitative studies based on populations from high‐income countries. The review was conducted by two independent reviewers. Risk of bias was assessed. Rates of obstetric violence were pooled using random effects model, computing 95% confidence intervals (CI) and assessing heterogeneity using I2 statistic. Funnel plots and Egger's test were used to detect potential reporting biases and small‐study effects. Results Of the 1821 records screened, 25 studies were included: 14 quantitative and 2 mixed methods studies, comprising 60 987 women, and 9 qualitative studies were included, comprising an additional 4356 women. 81.25% of quantitative studies, including the quantitative component of the mixed methods studies, were considered satisfactory or better regarding risk of bias. The prevalence of obstetric violence was overall 45.3% (95% CI 27.5–63.0; I2 = 100.0%). The prevalence of specific forms of mistreatment was also estimated. Lack of access to analgesia was 17.3% (95% CI 6.9–27.7; I2 = 99.7%). Ignored requests for help was 19.2% (95% CI 11.7–26.6; I2 = 99.0%). Shouting and scolding 19.7% (95% CI 13.0–26.4; I2 = 98.7%). The use of fundal pressure during the second stage of labor (Kristeller maneuver) was 30.3% (95% CI 22.1–38.5; I2 = 97.6%). There was no funnel asymmetry. Lack of information and/or consent were the most frequent domains extracted from the qualitative articles and the qualitative component of the mixed methods studies. Conclusions The results demonstrate that obstetric violence is a prevalent problem that women in high‐income countries experience. Lack of information and/or consent were the domains most frequently described in the qualitative studies and the qualitative component of the mixed methods studies. Physical, verbal and psycho‐social obstetric violence were found to be highly prevalent in high‐income countries. Coercion and lack of information or consent were some of the domains most frequently reported by women across all study types.

Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. We measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania. Using a structured questionnaire, we interviewed women who had delivered in health facilities upon discharge and re-interviewed a randomly selected subset 5–10 weeks later in the community. We calculated frequencies of 14 abusive experiences and the prevalence of any disrespect/abuse. We performed logistic regression to analyse associations between abusive treatment and individual and birth experience characteristics. A total of 1779 women participated in the exit survey (70.6% response rate) and 593 were re-interviewed at home (75.8% response rate). The frequency of any abusive or disrespectful treatment during childbirth was 343 (19.48%) in the exit sample and 167 (28.21%) in the follow-up sample; the difference may be due to courtesy bias in exit interviews. The most common events reported on follow-up were being ignored (N=84, 14.24%), being shouted at (N=78, 13.18%) and receiving negative or threatening comments (N=68, 11.54%). Thirty women (5.1%) were slapped or pinched and 31 women (5.31%) delivered alone. In the follow-up sample women with secondary education were more likely to report abusive treatment (odds ratio (OR) 1.48, confidence interval (CI): 1.10–1.98), as were poor women (OR 1.80, CI: 1.31–2.47) and women with self-reported depression in the previous year (OR 1.62, CI: 1.23–2.14). Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is a health system crisis that requires urgent solutions both to ensure women’s right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.

High-quality obstetric delivery in a health facility reduces maternal and perinatal morbidity and mortality. This systematic review synthesizes qualitative evidence related to the facilitators and barriers to delivering at health facilities in low- and middle-income countries. We aim to provide a useful framework for better understanding how various factors influence the decision-making process and the ultimate location of delivery at a facility or elsewhere. We conducted a qualitative evidence synthesis using a thematic analysis. Searches were conducted in PubMed, CINAHL and gray literature databases. Study quality was evaluated using the CASP checklist. The confidence in the findings was assessed using the CERQual method. Thirty-four studies from 17 countries were included. Findings were organized under four broad themes: (1) perceptions of pregnancy and childbirth; (2) influence of sociocultural context and care experiences; (3) resource availability and access; (4) perceptions of quality of care. Key barriers to facility-based delivery include traditional and familial influences, distance to the facility, cost of delivery, and low perceived quality of care and fear of discrimination during facility-based delivery. The emphasis placed on increasing facility-based deliveries by public health entities has led women and their families to believe that childbirth has become medicalized and dehumanized. When faced with the prospect of facility birth, women in low- and middle-income countries may fear various undesirable procedures, and may prefer to deliver at home with a traditional birth attendant. Given the abundant reports of disrespectful and abusive obstetric care highlighted by this synthesis, future research should focus on achieving respectful, non-abusive, and high-quality obstetric care for all women. Funding for this project was provided by The United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization.

Background High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care. Methods Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded. Findings Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients’ attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being. Conclusions The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.

Background Poor quality of care at health facilities is a barrier to pregnant women and their families accessing skilled care. Increasing evidence from low resource countries suggests care women receive during labor and childbirth is sometimes rude, disrespectful, abusive, and not responsive to their needs. However, little is known about how frequently women experience these behaviors. This study is one of the first to report prevalence of respectful maternity care and disrespectful and abusive behavior at facilities in multiple low resource countries. Methods Structured, standardized clinical observation checklists were used to directly observe quality of care at facilities in five countries: Ethiopia, Kenya, Madagascar, Rwanda, and the United Republic of Tanzania. Respectful care was represented by 10 items describing actions the provider should take to ensure the client was informed and able to make choices about her care, and that her dignity and privacy were respected. For each country, percentage of women receiving these practices and delivery room privacy conditions were calculated. Clinical observers’ open-ended comments were also analyzed to identify examples of disrespect and abuse. Results A total of 2164 labor and delivery observations were conducted at hospitals and health centers. Encouragingly, women overall were treated with dignity and in a supportive manner by providers, but many women experienced poor interactions with providers and were not well-informed about their care. Both physical and verbal abuse of women were observed during the study. The most frequently mentioned form of disrespect and abuse in the open-ended comments was abandonment and neglect. Conclusions Efforts to increase use of facility-based maternity care in low income countries are unlikely to achieve desired gains if there is no improvement in quality of care provided, especially elements of respectful care. This analysis identified insufficient communication and information sharing by providers as well as delays in care and abandonment of laboring women as deficiencies in respectful care. Failure to adopt a patient-centered approach and a lack of health system resources are contributing structural factors. Further research is needed to understand these barriers and develop effective interventions to promote respectful care in this context.

Concerns about disrespect and abuse (D&A) experienced by women during institutional birth have become critical to the discourse on maternal health. The rapid growth of the field from diverse points of origin has given rise to multiple and, at times, confusing interpretations of D&A, pointing to the need for greater clarity in the concepts themselves. Furthermore, attention to measurement of the problem has been excessive when viewed in relation to the small amount of work on critical drivers of disrespect and abuse. This paper raises some key issues of conceptualisation and measurement for the field, puts forward a working definition, and explores two critical drivers of D&A - intersecting social and economic inequality, and the institutional structures and processes that frame the practice of obstetric care. By identifying gaps and raising questions about the deeper causes of D&A, we point to potentially fruitful directions for research and action.

Background Several studies have identified how mistreatment during labour and childbirth can act as a barrier to the use of health facilities. Despite general agreement that respectful maternity care (RMC) is a fundamental human right, and an important component of quality intrapartum care that every pregnant woman should receive, the effectiveness of proposed policies remains uncertain. We performed a systematic review to assess the effectiveness of introducing RMC policies into health facilities providing intrapartum services. Methods We included randomized and non-randomized controlled studies evaluating the effectiveness of introducing RMC policies into health facilities. We searched PubMed, CINAHL, LILACS, AJOL, WHO RHL, and Popline, along with ongoing trials registers (ISRCT register, ICTRP register), and the White Ribbon Respectful Maternity Care Repository. Included studies were assessed for risk of bias. Certainty of evidence was assessed using GRADE criteria. Findings Five studies were included. All were undertaken in Africa (Kenya, Tanzania, Sudan, South Africa), and involved a range of components. Two were cluster RCTs, and three were before/after studies. In total, over 8000 women were included at baseline and over 7500 at the endpoints. Moderate certainty evidence suggested that RMC interventions increases women’s experiences of respectful care (one cRCT, approx. 3000 participants; adjusted odds ratio (aOR) 3.44, 95% CI 2.45–4.84); two observational studies also reported positive changes. Reports of good quality care increased. Experiences of disrespectful or abusive care, and, specifically, physical abuse, were reduced. Low certainty evidence indicated fewer accounts of non-dignified care, lack of privacy, verbal abuse, neglect and abandonment with RMC interventions, but no difference in satisfaction rates. Other than low certainty evidence of reduced episiotomy rates, there were no data on the pre-specified clinical outcomes. Conclusion Multi-component RMC policies appear to reduce women’s overall experiences of disrespect and abuse, and some components of this experience. However, the sustainability of the demonstrated effect over time is unclear, and the elements of the programmes that have most effect have not been examined. While the tested RMC policies show promising results, there is a need for rigorous research to refine the optimum approach to deliver and achieve RMC in all settings.

Aim To synthesise qualitative studies on nurses’ and midwives’ perspectives and experiences of Obstetric Violence, exploring Obstetric Violence from a non-patient perspective. Design A qualitative meta-synthesis. Methods A systematic search was undertaken across multiple electronic databases, including PubMed, Web of Science, Embase, and CINAHL, to identify relevant studies published from database inception to April 1, 2025. The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Relevant qualitative data were subsequently extracted, coded, and synthesised. Results This meta-synthesis incorporated 13 qualitative studies conducted across 13 countries. In total, there were 440 participants in all studies. A total of 40 themes were identified and subsequently synthesised into 11 categories, which were further integrated into four major synthesised findings: (1) Who is the Perpetrator; (2) Obvious and Hidden Harm; (3) Another Victim; (4) The strategies to prevent OV. Conclusion The causes of OV extend beyond the actions of individual providers or isolated organisational failings and should be considered within a broader, multidimensional framework. OV manifests in both direct and indirect forms, with the latter often being less visible yet equally harmful to women. These subtler manifestations warrant greater recognition and attention. Within this context, nurses and midwives may also experience OV as secondary victims, underscoring the need for targeted interventions, such interventions include individual-level strategies, such as yoga, massage, and mindfulness, as well as organizational-level interventions such as Balint groups, to address their psychological distress, moral concerns, and burnout. Moving forward, strategies to reduce OV should adopt a coordinated, top-down approach involving action at societal, organisational, and individual levels.

Background In many countries, rates of facility-based childbirth have increased substantially in recent years. However, insufficient attention has been paid to the acceptability and quality of maternal health services provided at facilities and, consequently, maternal health outcomes have not improved as expected. Disrespect and abuse during childbirth is increasingly being recognized as an indicator of overall poor quality of care and as a key barrier to achieving improved maternal health outcomes, but little evidence exists to describe the scope and magnitude of this problem, particularly in urban areas in low-income countries. Methods This paper presents findings from an assessment of the prevalence of disrespectful and abusive behaviors during facility-based childbirth in one large referral hospital in Dar es Salaam, Tanzania. Client reports of disrespect and abuse (D&A) were obtained through postpartum interviews immediately before discharge from the facility with 1914 systematically sampled women and from community follow-up interviews with 64 women four to six weeks post-delivery. Additionally, 197 direct observations of the labor, delivery, and postpartum period were conducted to document specific incidences of disrespect and abuse during labor and delivery, which we compared with women’s reports. Results During postpartum interviews, 15 % of women reported experiencing at least one instance of D&A. This number was dramatically higher during community follow-up interviews, in which 70 % of women reported any experience of D&A. During postpartum interviews, the most common forms of D&A reported were abandonment (8 %), non-dignified care (6 %), and physical abuse (5 %), while reporting for all categories of D&A, excluding detention and non consented care, was above 50 % during community follow-up interviews. Evidence from direct observations of client-provider interactions during labor and delivery confirmed high rates of some disrespectful and abusive behaviors. Conclusions This study is one of the first to quantify the prevalence of disrespect and abuse during facility-based childbirth in a large public hospital in an urban setting. The difference in respondent reports between the two time periods is striking, and more research is needed to determine the most appropriate methodologies for measuring this phenomenon. The levels and types of disrespect and abuse reported here represent fundamental violations of women’s human rights and are symptomatic of failing health systems. Action is urgently needed to ensure acceptable, quality, and dignified care for all women.