The survey instrument with the four components measuring respect, autonomy in decision making, discrimination and mistreatment during pregnancy and childbirth is a valid and reliable tool for assessing the quality of intrapartum care experiences of childbearing women in Germany. This is the first study to document manifestations of disrespect and abuse during childbirth (D&A) in German maternity care. The results suggest that women in Germany experience disrespectful and abusive care similar to women in other high-income countries. The women’s reported experiences reflected all third-order themes of Bohren et al.’s (2015) typology of mistreatment during childbirth (16).
Non-consented care was the most commonly reported form of mistreatment: More than 40% of the participants reported that intrapartum interventions were carried out without their consent. These numbers confirm the findings of Begley, Sedlicka & Daly (2018) for the Czech Republic (36) and Morton et al. (2018) for USA and Canada (37), who found non-consented care to be the most often occurring form of disrespect and abuse observed by doulas, nurses and midwives. Compared to the participants in the Canada-based “Changing Childbirth in British Columbia” (21) study women in the current study experienced far more disrespect and coerced decision making during childbirth. For example, in British Columbia around 90% of the survey participants agreed to have felt comfortable asking questions while making decisions, to have felt comfortable accepting or declining care that was offered and that their personal preferences had been respected. In the present study only around half of the participants agreed to the respective items. Furthermore, almost 60% felt coerced into accepting care options their care provider suggested, compared to 13% in the British Columbia sample and around 20% in the US Giving Voice to Mothers study (18). With respect to autonomy in decision making, similar differences were observed: The median “Mothers’ Autonomy in Decision Making” (MADM) score was 18 in the present study, less than one third of the total scale range, and 39 in the British Columbia sample (38), which is very close to the highest possible scale score of 42. These discrepancies confirm the known selection bias resulting from recruitment via a mothers consumer organization representing women affected by obstetric violence in the present study, whereas the British Columbia study (21) embedded MOR and MADM into a large survey on maternity care experiences in a geographically and socioeconomically diverse population. In addition, the North American studies had a disproportionately high number of midwifery clients, and the US study also included many people who gave birth at home or in birthing centres (50% of sample). Previous research has shown that midwifery clients and those planning a community birth have much lower rates of mistreatment (18) and higher respect and autonomy scores (21, 38).
Being coerced into accepting interventions instead of being engaged in a process of informed decision-making during childbirth undermines women’s autonomy and constitutes a disrespectful and abusive practice. Coercion has been reported previously in the “Listening to Mothers III“ survey, a national survey of 2,400 US women who gave birth in US hospitals from mid-2011 to mid-2012 (24): Women experienced pressure from health professionals to accept labour induction (15%), epidural analgesia (15%), or caesarean section (13%). Similarly, in the “Giving Voice to Mothers” study, 13.0% felt pressured to have labour induction, 7.3% to have epidural analgesia, and 10.6% to have a caesarean Sect. (18).
In the current study, one third of the participating women reported physical abuse. This constitutes a large proportion compared to the few “Giving Voice to Mothers” survey participants who agreed to the respective item (1.3%)(18). Besides the selection bias towards women affected by abusive intrapartum care in the present study, a broader definition of physical abuse may explain this difference. As suggested by the German experts, painful vaginal examinations and insufficient anesthesia for the suture of an episiotomy were included as additional examples in the translated item.
The high number of women reporting the use of fundal pressure by maternity care providers in the second stage of labor is another important finding of the current study. Twenty-seven percent of the survey participants have experienced this intervention for which there is insufficient evidence (39). Fundal pressure is commonly used with the indication of maternal exhaustion or suspected fetal distress in order to avoid instrumental birth but often it is applied without formal indication (40). According to the guidelines of the International Childbirth Initiative (41), fundal pressure is among the harmful procedures to be avoided; in addition, its use is not recommended by the WHO (1). For women, this intervention is frequently experienced as physical violence and can be traumatising (28, 42).
Violation of physical privacy also was a frequently reported experience in the present sample, which is congruent with findings from Vedam et al. (18). Being uncovered and having unknown people, e.g. medical students, watching the birth without the woman’s consent can cause distress and loss of dignity as qualitative research showed (43–45).
A large number of women in the present study felt ignored or did not get help when needed. Both quantitative and qualitative studies found neglect and abandonment to be one of the most frequently cited mistreatment experiences and is linked to women’s perceptions of traumatic childbirth (4, 18, 46). Neglect and abandonment of childbearing women, next to indicating disrespectful attitudes of care providers or a disrespectful facility culture, are likely to also be a consequence of structural constrains leading to staffing shortage, which is described by Bohren et al. (16) under the theme “health system conditions and constraints”. The shortage of midwives in German hospitals – with one midwife caring for up to four labouring women (47) – may play a key role for failure of professional standards and meeting women’s needs. Given the fact that a delayed response to clinical warning signs has been found to be one of the most common types of contributors to maternal deaths (48), these findings are alarming, especially in a high resource setting.
Finally, large numbers of women in the current study reported verbal abuse – shouting, scolding or threatening – resonating with Vedam et al.’s (18) findings and confirming Beck’s (46) qualitative observations of harsh language, threats and blaming of childbearing women by intrapartum caregivers. Racially or sexually demeaning language as well as threats that a baby might die if a woman did not comply with a proposed procedure were often witnessed in Morton et al.’s (37) study of doulas’ and nurses’ observations of disrespectful maternity care. Such care provider threats were also reported by Reed, Sharman & Inglis (5), in their global online survey among women with traumatic birth experience, mainly from Australia, Oceania, North America and Europe.
Overall, the survey instrument in the current study showed very good psychometric properties. Feedback from the pilot testing phase and the expert review provided support for the content validity of all included measures. The internal consistency reliability of included scales exceeded 0.95 and was high compared to other published tools in the area of research (13–15) and comparable to the findings of the scale developers (21, 22). Similarly to the original scales, very high item-to-total correlations above 0.7 were found for MOR-7 and for MADM, i.e. each single item strongly correlated with the sum of all other items of the respective scale, thus providing strong evidence for the homogeneity of these scales (49).
Because of their homogeneity, uni-dimensionality of the scales was assumed. Factor analysis confirmed this assumption for all scales: With only one eigenvalue larger than one, scree plots showing a clear elbow curve and high loadings on one factor, MOR7, MORG and MADM – similarly to the original scales – form uni-dimensional scales with good construct validity. Future users of the MORG scale might discuss eliminating item f (“During my birth I held back from asking questions or discussing my concerns because my doctor or midwife didn’t use language that I could understand.”) because of its far lower factor loading in comparison to the other items of this scale.
The almost perfect correlation between MORG and MOR7 allows to consider the use of MOR7 as sufficient for the assessment of respectful care. It would be a short and effective measure and, as it has not been altered in the validation process, it may be more useful for international comparisons than the adapted version MORG. On the other hand, MORG integrates more aspects of respectful care drawing a broader picture of the construct respect. In consequence, for German prevalence or intervention studies MORG would be the preferable option.
Finally, strong and significant negative correlations of MOR7, MORG and MADM scale scores with PSSSR scale scores assessed convergent validity of these scales, thus further confirming construct validity. Based on scientific evidence on the relationship between inappropriate intrapartum care and trauma (2, 3, 5, 29, 43), it has been hypothesized that low perceived respect or autonomy during childbirth would be associated with increased posttraumatic stress symptoms. Hollander et al. (50), for example, found lack of autonomy in decision making to be attributed to childbirth trauma by 30% of the participants of their cross-sectional survey conducted in the Netherlands among 2,192 women with a self-reported traumatic birth experience. However, measures of respectful care, autonomy in decision making or mistreatment during childbirth have never been correlated with validated measures of postpartum PTSD before. A strong association of indicators of obstetric violence with postpartum depression has recently been assessed in a Brazilian cross sectional study with 10,468 women (51): Women who experienced neglect, verbal violence, or physical violence were found to have an up to seven times higher risk of developing postpartum depression than women without these experiences. It has to be noted, however, that the authors did not use a validated instrument to measure obstetric violence.
Strengths and limitations of the study
The present study is the first quantitative study on disrespect and abuse during childbirth (D&A) in the German maternity care context. Furthermore, the current study assessed associations between indicators of D&A and symptoms of postpartum posttraumatic stress disorder for the first time. Convergent validation against a measure of PTSD is a new and significant addition to the testing of validity and utility of the MOR and MADM scales.
Certainly, the high sample size is another strength of this study. As delineated above, the sample is not representative of the target population, and therefore generalisability of the results is limited. The selection bias towards women who experienced disrespect & abuse in the sample, however, facilitated tool validation in particular with regard to the relevance of the items. The recall bias is assumed to be minimal in this study because women’s recall of their childbirth experiences has been shown to be very accurate when compared to medical records, even 10 to 15 years after the event (52).
Due to a transcription error from paper to the survey software, the PSS-SR item “Did you have trouble concentrating?” was missing in the survey. One possibility to overcome this problem could have been to replace the missing values by the respective means of the other 16 values to get an estimate of the PSS-SR scores. Although this option is an established statistical procedure to deal with a moderate number of missing data, it is not recommended when all values are missing because it can severely distort results of analyses (35). All calculations therefore were made with the remaining 16 items. The Cronbach’s alpha was higher than has been reported for the original scale (30) and also higher than in later studies using the PSS-SR postpartum (33, 53, 54). Therefore the 16-item scale was considered to be valid and useful for the purpose of this study to assess convergent validity between the constructs of respect, autonomy in decision making, and mistreatment and the construct of postpartum posttraumatic stress. The missing item, which refers to difficulties concentrating after the event, moreover, can be considered as one of the less meaningful symptoms when used to assess posttraumatic stress in the puerperium. Difficulties concentrating may be normal in this phase of reorientation, often accompanied by lack of sleep, instead of indicating trauma.
Despite the strong associations observed between indicators of D&A with postpartum PTSD symptoms, causality cannot be assumed because of the cross-sectional nature of the study measuring outcome and exposure simultaneously. Furthermore, the survey participants were not screened for prior trauma, one of the main predictors of postpartum PTSD (2).