A total of 60 interviews were conducted (women: 24 interviews; healthcare providers: 29 interviews; and managers: 7 interviews). Tables 2 and 3 show the demographic characteristics of the participants. Three people refused to participate in the study including a manager who did not respond to our invitation and two healthcare providers who expressed concerns about lack of time. The results are presented in two sections: first, an overview of the experiences and manifestations of mistreatment during labour and childbirth, followed by the factors affecting the mistreatment, which is the main focus of this article.
Table 2
Women’s sociodemographic characteristics
| Frequency (%) |
Number | 24 (100.0) |
Age (years) | |
< 20 | 2 (8.3) |
21–30 | 16 (66.7) |
31–40 | 6 (25.0) |
Education | |
Illiterate | 2 (8.3) |
Primary | 7 (29.2) |
Cycle | 3 (12.5) |
Diploma | 6 (25.0) |
University | 6 (25.0) |
Job | |
Housewife | 21 (87.5) |
Employed | 3 (12.5) |
Nationality | |
Iranian | 17 (70.8) |
Afghan | 7 (29.2) |
Family income (self-report) | |
Low | 8 (33.3) |
Middle | 14 (58.3) |
High | 2 (8.3) |
Service provider type | |
Resident | 20 (83.3) |
Midwife | 0 (0.0) |
Obstetrician | 0 (0.0) |
Do not Know | 4 (16.7) |
Number of living children (including most recent birth) | |
0–1 | 12 (50.0) |
2–3 | 10 (41.7) |
≥ 4 | 2 (8.3) |
Table 3
Healthcare providers’ and managers’ demographic characteristics
| Doctors | Midwives | Managers |
Number | 13 | 16 | 7 |
Age (years) | | | |
25–34 | 12 | 6 | 0 |
35–44 | 1 | 8 | 0 |
45–54 | 0 | 2 | 3 |
≥ 55 | 0 | 0 | 4 |
Marital status | | | |
Single | 6 | 6 | 1 |
Married | 7 | 10 | 6 |
Work experience (years) | | | |
≤ 5 | 12 | 5 | 0 |
6–10 | 1 | 3 | 0 |
11–15 | 0 | 5 | 1 |
> 15 | 0 | 3 | 6 |
Types of mistreatment experienced during labour and childbirth
Four main categories of mistreatment including physical abuse, verbal abuse, failure to meet professional standards of care, and poor rapport between women and providers were emerged from the analysis of data about women's experiences.
Physical and verbal abuse
Some women complained of pressure on their abdomen by healthcare providers during childbirth, calling it an “agonizing” behavior. While the providers stated that sometimes they had to use fundal pressure to save the baby's life.
“During childbirth, she pressed my abdomen so hard that my abdomen turned blue. I told her ‘not to push’. She said ‘be quiet and help. My ribs hurt.” (Woman 21, 32 years old)
Judgmental comments and harsh and rude language were the most common forms of mistreatment experienced by women. This verbal abuse took several forms, including judgmental comments about a woman’s young age and shaming women for crying out from labour pains.
“During childbirth, when I was screaming, they said: Shut up, shut your mouth.” (Woman 23, 24 years old)
“They said to me: You who given birth before and have birth experience, aren’t you ashamed to shout? You have to endure the pain; you did not come here to have fun.” (Woman 13, 24 years old)
Another woman said: “I was told several times: why are you pregnant as a child? Do not have children anymore. This will be your first and last child.” (Woman 10, 21 years old)
Several women also reported inappropriate behavior of cleaners during childbirth: “Here, the cleaners also yells at us.” (Woman 21, 32 years old)
Some women also described being threatened of poor outcomes by the providers. However, the healthcare providers did not consider these threats to be mistreatment; they believed that it was an important means of getting the women’s cooperation, believing that these threats came from a place of caring and help, rather than malice.
“The doctor said: 'Madam, you do not push, your child will be handicapped.” (Woman 2, 27 years old)
“Yes, yes, we should threaten the mother that 'If you do not push, your baby will die'. Because if we do not threaten her, she will not push at all ... But I do not consider this as mistreatment because I want to help her.” (Midwife 1, 43 years old)
Failure to meet professional standards of care
Painful vaginal exams: All women interviewed complained of frequent and painful vaginal examinations. They reported that the providers performed the examination without explanation or permission.
“I hate to be examined by them. I think they examined me more than twenty times. With long nails, it really agonizes. They came quickly, put on gloves, and started the examination ... Now I see a nurse wearing gloves and coming towards me, I'm scared.” (Woman 9, 27 years old)
Neglect and abandonment: The narrations of the women showed that many suffered from neglect and abandonment by the healthcare providers. The providers refused to sympathize with them during labour or left them alone after birth.
“In the labour room, no matter how much I shouted. No one paid attention to me until the birth.... When the baby was born, I was left alone again because another woman was in pain and all the doctors and midwives went to take care of her. I was very scared because there was no one by my side to help.” (Woman 6, 18 years old)
Refusal to provide pain relief: Ignoring women's requests for pain relief during childbirth has also been reported by several women:
“She did not use painkillers for me. She said, 'There will be four stitches; it's not worth using painkillers. Be patient.” (Woman 23, 24 years old)
Poor rapport between women and providers
Reports from women and some midwives indicated a lack of supportive care for women during labour and childbirth. They stated that healthcare providers do not allocate time for them to have an emotional relationship with women or to provide information throughout labour and birth.
“I was much stressed. My whole body was shaking. She was my first child and was to be born sooner. Instead of explaining or encouraging me, they said, 'Shut up, does anyone cry because of childbirth?” (Woman 12, 19 years old)
“We do not have an emotional relationship with the mother at all. She likes us to explain to her, for example, what is going to happen to her and what the delivery process is like, but unfortunately we do not spend time on it at all.” (Midwife 3, 40 years old)
Denial of mobility during labour was also an important source of dissatisfaction for women. They were often connected to the monitors and had no right to walk or move. The midwives explained that residents may have to monitor women tightly because of their legal responsibilities to the health of both mother and baby.
“I was not allowed to get out of bed at all. I said let me walk, but they connected that device to me and I had to lie down, and this was kind of torture.” (Woman 14, 38 years old)
Influencing factors of mistreatment during labour and childbirth
We identified four main themes for factors influencing mistreatment during labour and childbirth: Individual-level factors, healthcare provider-level factors, hospital level-factors and national health system-level factors (Table 4).
Theme 1: Individual-level factors
Our study showed that healthcare providers believed that women’s limited knowledge about labour and childbirth process, and untrained companions caused mistreatment by them. Moreover, mismatched expectations of women for care, and discrimination based on ethnicity or low socioeconomic status were among the most important factors of mistreatment.
Perception of healthcare providers about women’s limited knowledge on labour and childbirth process
Prenatal education is a good opportunity to empower women, and increase their self-efficacy and cooperation during labour and childbirth. However, healthcare providers reported poor knowledge of pregnant women about labour and childbirth processes as major factor of mistreatment. They believed that despite being free of charge, most women did not attend childbirth preparation classes, and this lack of knowledge plays an important role in their lack of “cooperation” during childbirth and mistreatment.
“Unfortunately, many women do not have the knowledge of birth processes and are not ready to give birth. They expect to give birth as soon as they arrive at the maternity ward and then return home. If the woman knows what a normal birth is like; how long does it take; what should she do at each stage of labour; I do not need to shout at her.” (Resident 7, 32 years old)
Untrained companions
Some healthcare providers reported that the presence of untrained lay companions was another factor contributing to the experience of mistreatment. They believed that the companions should have received the necessary training in order to be able to help the birthing women, while they did not have enough information and interrupt unnecessarily in the childbirth process.
“Companions are completely unaware, completely unaware, their interference makes us angry, and this may lead to aggression with the mother. For this reason, we (healthcare providers) do not agree with the constant presence of an untrained companion.” (Obstetrician 5, 33 years old)
Mismatched expectations of women for care
Some healthcare providers considered the high levels of women's expectations for receiving high quality services as another factor for their mistreatment. Because this factor often caused women to be abusive to the providers and ultimately to provoke sharp reactions from the providers.
“Some women are very expectant. They expect care like private hospitals, meaning having private doctor and midwife.” (Resident 3, 30 years old)
Discrimination based on ethnicity or low socioeconomic status
Both healthcare providers and women believed that being women who were not Iranian may be at higher risk of mistreatment. In Tehran, this was particularly true for Afghan women:
“Many of the women referred to our hospital are Afghan women, some of whom do not understand our language at all and do not cooperate well with us. Usually this causes a sharp reaction from us.” (Midwife 17, 50 years old)
“When I was in the delivery room, they said, ‘Afghans again, these Afghans are everywhere we go’ ... We were offended by their words. I saw that Iranian women were treated better.” (Woman 16, 23 years old)
Women with low economic status are more likely to experience mistreatment. Because most women who go to public hospitals are in poor financial condition, they inevitably accept any kind of care from a healthcare provider. Furthermore, the level of education of women was so important that illiteracy or low education prevented them from receiving respectful care.
“I think a group of people come here (public hospitals) who are either illiterate or financially compelled. They have no other choice, so they tolerate any situation and their voice is not heard. Otherwise, who would like to be treated like this?” (Hospital level manager, 55 years old)
“Most of my friends told me not to go to X hospital. The behavior of its staff is very bad. They will harass you; it looks like you are a laboratory rat. But because the cost was low, I had to come here.” (Woman 12, 19 years old)
Theme 2: Healthcare provider-level factors
Healthcare provider stress and stressful working conditions, healthcare providers with limited personal experience of pregnancy and childbirth, neglect of midwives' identities by doctors, poor educational contents and curriculum, and low salary and lack of incentive were the factors identified at the healthcare provider-level.
Healthcare provider stress and stressful working conditions
High anxiety and stressful working conditions of the healthcare providers can play a significant role in their way of behaving as a health staff. Some of them complained of pressure from seniors. Seniors were always under legal pressure of providing healthy childbirth outcome and they transfer the pressure to junior healthcare providers.
“The professors are also pressuring us. I think some of our professors are too sensitive. For example, when I have to take a non-stress test (NST) for a pregnant woman who has no problem at 3 o'clock in the morning, of course I get nervous. Because I can't find the fetus's heart, I vent my anger on the patient. ‘Pull down your pants, lady, hurry; you have no right to move until I get a good NST’, this happens many times and the reason is that when the senior resident or professor comes, the NST should be in the patient's file.” (Resident 12, 27 years old)
Moreover, the high workload and long hour shifts of healthcare providers, especially residents, were another factor stated by the participants that created the ground for mistreatment of women by creating physical and mental fatigue.
“A resident who has to spend a 36-hours shift cannot be expected to be kind to patient.” (Resident 10, 28 years old)
Healthcare providers with limited personal experience of pregnancy and childbirth
Lack of provider experience of pregnancy and/or childbirth was identified as a factor influencing the quality of care. Participants emphasized that most providers (especially resident doctors as the primary maternity providers) are young. They are often single or have not experienced pregnancy or childbirth, and both healthcare providers themselves and women believed that this lack of understanding and empathy can be accompanied by mistreatment.
“Most (healthcare providers) are young, maybe they do not have the experience of motherhood and childbirth, and they do not understand what the pain of childbirth is?” (Woman 3, 38 years old)
“I have two children; I had a vaginal delivery, the way I treat a pregnant woman is far different from a single resident because I experienced the pain of childbirth, the pain is really terrible, I am more patient with the sighs and groans she makes.” (Resident 4, 33 years old)
Neglect of midwives' identities by doctors
Proper communication between healthcare providers plays an important role in providing quality and respectful care. However, midwives indicated that there is no good interaction between the obstetric residents and the midwives.
“The relationship between the resident and the midwife is not very good. How can one expect respect for the patient when they do not value us?” (Midwife 4, 37 years old)
Furthermore, most midwives stated that obstetricians and residents should work mostly in the field of surgery and high-risk clinical activities; and midwives should be responsible for caring for women during labour and birth, particularly involving empathy and low risk timely care for women. Therefore, in order to improve the quality of obstetrics care and respecting pregnant women, it is necessary to review the job descriptions of maternity ward providers in public hospitals.
“Midwives have no place in the teaching hospitals. I only do paper works and have no clinical responsibility as a midwife to give birth. Why shouldn't midwife control labour process?” (Midwife 14, 40 years old)
“Description of midwives duties in a teaching hospital should be clearly defined. We suggested that low-risk delivery be performed by midwives and high-risk delivery by Obstetricians.” (MOHME level manager, 51 years old)
Poor educational contents and curriculum
Training gaps for healthcare providers were reported as an important factor for mistreatment by most participants. They believed that they have not well trained about medical ethics or the way to communicate with women during labour and birth. As a result, they feel that they are not sufficiently prepared to provide respectful care for women. They believed that it should be included in their curriculum as a separate course.
“We do not have enough information about dis/respectful maternity care, I have only passed a communication skills training course during my studies that had not that much information on respectful care.” (Resident 2, 31 years old)
“Doctors or midwives are clinically literate, but they do not know how to treat a patient respectfully. I think it is necessary to hold regular training courses for them.” (Woman 18, 27 years old)
Low salary and lack of incentive
Most healthcare providers believed that low salary, along with a system of punishment, instead of encouragement and reward, affected the quality of care provided by them and the quality of relationship with patients.
“When you are not paid well and you are not satisfied financially, this can automatically affect your behavior.” (Hospital level manager, 55 years old)
Theme 3: Hospital-level factors
Factors of disrespectful maternity care at hospital level include: lack of staff, lack of supervision and control, type of hospital, and inadequate physical structures.
Lack of staff
All healthcare providers complained about staff shortages. For them, performing the clinical routine tasks and paper work was a priority, and caring for women with respect was not prioritized. They also noted that the patient-to-staff ratio increases their job demands, meaning that the resident or midwife is forced to perform tasks that are not defined in their area of responsibility.
“The patient input is very high; for example, each midwife has to cover 6 or 7 patients, which means that we are just running here to do the patient's clinical and paper works correctly. So, we cannot treat all of them properly.” (Midwife 3, 40 years old)
Lack of supervision and control
The women's report showed that maternity ward managers did not monitor the performance of healthcare providers. They believed that continuous monitoring of providers' performance was required to reduce disrespectful maternity care. This issue was also emphasized by some managers.
“There is no management and supervision. If they punish the provider who mistreated, the rest will definitely perform better.” (Woman 19, 25 years old)
“A person, for example, maternity supervisor, should be responsible for monitoring the behavior of staff with women and have the authority to warn if someone disrespects them.” (MOHME level manager, 55 years old)
Type of hospital
Women believed that the type of hospital was important in receiving quality care. They thought that women in public teaching hospitals were more likely to experience mistreatment due to high work load of staff and lower costs.
“The more money you pay, the better they will treat you. I think a private hospital is better.” (Woman 9, 27 years old)
Inadequate physical structures
Good quality care requires sufficient physical infrastructure. Healthcare providers stated that the lack of physical space in some maternity wards poses a challenge to the privacy of pregnant women as well as the presence of a companion. Moreover, the providers complained about the lack of adequate space for their rest during long shifts.
“We do not have a good space here. The women were separated by the curtain, which is either torn or we have to constantly push it aside so we can see the fetal heart monitor, so privacy is not respected.” (Resident 6, 27 years old)
“Unfortunately, we do not have space for companions; even our residents do not have a suitable place to rest in this hospital.” (Obstetrician 13, 43 years old)
Theme 4: National health system-level factors
In this study, poor implementation of existing policies and guidelines was identified as another factor in the mistreatment of women.
Lack of access to pain management during labour and childbirth
Midwives and residents reported that pregnant women did not have sufficient options for pain management during labour, including use of epidurals.
“In our hospital, almost no painless normal delivery is performed. It is very difficult for us to coordinate a painless normal delivery. Sometimes an anesthetist is so late that the woman gave birth. Thus, pain causes women not to cooperate. If a painless normal delivery is performed, women will definitely have a better experience of childbirth.” (Resident 9, 32 years old)
Perceptions about forced vaginal birth in public hospitals
Some women also complained about forced vaginal birth in public hospitals. They believed that public hospitals limited women’s abilities to express preferences for caesarean birth, and that by giving birth in a public hospital, doctors would force them to have a vaginal birth.
“The doctor told me that this is a public hospital, we do not perform Cesarean sections. Even if you are in pain for five days, you have to endure to give birth vaginally ... one of them tore my amniotic sac, forcing me to give birth normally.” (Woman 7, 28 years old)
“The doctor shouted at me and said, ‘Vaginal delivery is painful. If you could not stand it, you would go to a private hospital for a Cesarean section.” (Woman 4, 29 years old)
Table 4 Themes and sub-themes of influencing factors of mistreatment during labour and childbirth reported by the multi-stakeholders
Themes
|
Sub-themes
|
Theme 1: Individual-level factors
|
Perception of healthcare providers about women’s limited knowledge on labour and childbirth process
|
Untrained companions
|
Mismatched expectations of women for care
|
Discrimination based on ethnicity or low socioeconomic status
|
Theme 2: Healthcare provider-level factors
|
Healthcare provider stress and stressful working conditions
|
Healthcare providers with limited personal experience of pregnancy and childbirth
|
Neglect of midwives' identities by doctors
|
Poor educational contents and curriculum
|
Low salary and lack of incentive
|
Theme 3: Hospital-level factors
|
Lack of staff
|
Lack of supervision and control
|
Type of hospital
|
Inadequate physical structures
|
Theme 4: National health system-level factors
|
Lack of access to pain management during labour and childbirth
|
Perceptions about forced vaginal birth in public hospitals
|