Measuring disrespect and abuse during childbirth in a high-resource country: Development and validation of a German self-report tool

Reliability and validity of measures of respectful care and discrimination for LGBTQ2S+ pregnant people

PROBLEM

There are no measures of respectful perinatal care validated within Lesbian, Gay, Bisexual, Transgender, Queer, Two-Spirit, and other sexual/gender minoritized (LGBTQ2S+) communities.

BACKGROUND

The LGBTQ2S+ community frequently experiences disrespect and discrimination in health care settings. While several instruments and scales have been developed to measure respectful perinatal (maternity) care, none have yet been adapted nor validated within the LGBTQ2S+ community.

AIMS

The aim of this study is to validate three scales measuring aspects of respectful perinatal care for use within LGBTQ2S+ pregnancy care experience research.

METHODS

This analysis of data from the 'Birth Includes Us' pilot study was collected via a community-developed survey assessing pregnancy care experiences of LGBTQ2S+ families. We assessed the psychometric properties of three adapted instruments, the Intersectional Day-to-Day Discrimination Index (InDI-D), the Measure of Autonomy and Decision Making (MADM), and the Measure of Respect index (MORi).

FINDINGS

All adapted scales performed well, with Cronbach's alphas greater than 0.8 across all measures. Scale scores for the preconception and pregnancy care versions of the MADM and MORi were 0.38 and 0.37 respectively, indicating that these care experiences were significantly different from one another.

DISCUSSION

The adapted versions of the InDI-D, MADM, and MORi performed well among LGBTQ2S+ families in their preconception and pregnancy care experiences and will be essential for future studies examining respectful perinatal care among these communities.

CONCLUSION

We recommend utilization of these validated measures to assess and address inequities in pregnancy-related care experiences for LGBTQ2S+ individuals and families.

Obstetric Violence Against Women in the Portuguese Context: A Qualitative In-Depth Approach

Evidence suggests that women worldwide experience mistreatment during institutional childbirth. This qualitative study aimed to explore obstetric violence in Portugal, specifically, its related factors and perceived impact. The inductive thematic analysis of 19 semi-structured interviews with women living in Portugal (22-41 years old), who identified themselves as victims, revealed six central themes: (1) obstetric violence, (2) the impact of obstetric violence, (3) victims' awareness, (4) coping strategies, and (5) explanatory factors. This study adds relevant evidence on what (experiences), why (explanatory factors), and how (processes and coping strategies) obstetric violence might occur, as well as its psychological, interpersonal, and physical impacts.

The moral dilemma of obstetric violence: A meta-synthesis

Although the global healthcare system is paying increasing attention to obstetric violence, this form of gender-based violence during childbirth remains a serious issue. The primary objective of this comprehensive study is to explore the experiences and needs of women subjected to obstetric violence on a global scale. A systematic search was conducted in December 2024 across the Web of Science, Embase, PubMed, and CINAHL databases to identify eligible studies. Data synthesis was performed using the three-stage thematic and content analysis method. A total of 39 eligible qualitative studies were included in this review. Thematic synthesis identified 6 themes and 17 sub-themes: (1) Obstetric Violence Types; (2) Gaslighting Effect: The Authoritative Position of Healthcare Providers; (3) Stigmatization and Discrimination Experienced by Women; (4) Who is Normalizing Obstetric Violence? (5) Substandard Medical Institutions; (6) Trauma Induced by Obstetric Violence. Obstetric violence continues to persist in various countries and regions. Women have endured various forms of obstetric violence, with their autonomy and rights to informed consent being severely compromised. They have experienced neglect and abandonment by healthcare providers, and face discrimination and differential treatment due to factors such as race, socioeconomic status, age, and culture. The primary cause of obstetric violence is the unequal power dynamics between healthcare providers and women, with the authoritative position of healthcare providers leading to a lack of communication and recognition between both parties.

In search of respect and continuity of care: Hungarian women's experiences with midwifery-led, community birth

INTRODUCTION

To describe and compare intervention rates and experiences of respectful care when Hungarian women opt to give birth in the community.

METHODS

We conducted a cross-sectional online survey (N = 1257) in 2014. We calculated descriptive statistics comparing obstetric procedure rates, respectful care indicators, and autonomy (MADM scale) across four models of care (public insurance; chosen doctor or chosen midwife in the public system; private midwife-led community birth). We used an intention-to-treat approach. After adjusting for social and clinical covariates, we used logistic regression to estimate the odds of obstetric procedures and disrespectful care and linear regression to estimate the level of autonomy (MADM scale).

FINDINGS

In the sample, 99 (7.8%) saw a community midwife for prenatal care. Those who planned community births had the lowest rates of cesarean at 9.1% (public: 30.4%; chosen doctor: 45.2%; chosen midwife 16.5%), induced labor at 7.1% (public: 23.1%; chosen doctor: 26.0%; chosen midwife: 19.4%), and episiotomy at 4.44% (public: 62.3%; chosen doctor: 66.2%; chosen midwife: 44.9%). Community birth clients reported the lowest rates of disrespectful care at 25.5% (public: 64.3%; chosen doctor: 44.3%; chosen midwife: 38.7%) and the highest average MADM score at 31.5 (public: 21.2; chosen doctor: 25.5; chosen midwife: 28.6). In regression analysis, community midwifery clients had significantly reduced odds of cesarean (0.35, 95% CI 0.16-0.79), induced labor (0.27, 95% CI 0.11-0.67), episiotomy (0.04, 95% CI 0.01-0.12), and disrespectful care (0.36, 95% CI 0.21-0.61), while also having significantly higher average MADM scores (5.71, 95% CI 4.08-7.36).

CONCLUSIONS

Hungarian women who plan to give birth in the community have low obstetric procedure rates and report greater respect, in line with international data on the effects of place of birth and model of care on experiences of perinatal care.

Measuring autonomy and respect: A qualitative, cross-cultural adaptation of the Mothers Autonomy in decision making scale and mothers on respect index instruments in Danish

OBJECTIVE

Decision-making is important in user-involved maternity care and patient experience instruments Mothers Autonomy in Decision Making scale (MADM) and Mothers on Respect index (MORi) are used internationally to measure the user involvement quality and users' experiences of autonomy and respect. This study aimed to translate and qualitatively adapt the original MADM and MORi instruments to the Danish language and culture.

METHODS

A forward and backward translation using a standard guideline. Subsequently, qualitative interviews to refine the translation and cultural adaptation by pilot testing the scales.

RESULTS

The translation process showed cultural differences linked to linguistic variations between Danish and English. Cognitive interviews with 14 diverse pregnant women revealed challenges in women's understanding of decision-making in maternity care. Changes in wording and assisting descriptive texts were made. Further, the order of the MADM items was changed to improve the understanding of decision-making.

DISCUSSION

Primarily, the discussion concerns how decision-making can be understood in the context of maternity care and why women's understanding of decision-making in Danish maternity care in the MADM scale items was challenged.

CONCLUSION

The qualitative pilot test using cognitive interviews after translation of the instruments was a valuable method for cultural adaptation providing important knowledge on women's understanding and perceptions of item contents. The cognitive interviews provided a comprehensive understanding of decision-making and contributed to a thoroughly worked Danish version of the MADM and MORi instruments.

Validation of the Greek version of Mothers on Respect (MOR) index

INTRODUCTION

Pregnancy is a critical period marked by vast changes, with a pivotal role in healthcare. The Mothers on Respect (MOR) index measures and ensures respect in maternal care, impacting health-seeking behaviors and postpartum outcomes vital for individual and healthcare system well-being. This study aims to validate the Greek version of the MOR index to enhance respectful maternity care and contribute to positive childbirth experiences.

METHODS

A retrospective, cross-sectional, descriptive, and analytical online survey collected data from Greek women with home childbirth experience. We utilized a self-administered questionnaire and the Greek version of the Mothers on Respect (MOR) index.

RESULTS

The MOR index, assessing knowledge and awareness, showed a median score of 78 points, with a significant association between higher scores and living in Attica or being a healthcare professional (p=0.027 and p=0.024, respectively). Confirmatory factor analysis indicated the questionnaire had an acceptable fit, and reliability was confirmed with Cronbach's α exceeding 0.7 across all dimensions.

CONCLUSIONS

The Greek MOR index validation advances respectful maternity care, enhances maternal health in Greece, and contributes to regional efforts for positive childbirth experiences.

Prevalence of obstetric violence in high-income countries: A systematic review of mixed studies and meta-analysis of quantitative studies

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.

Exposure to disrespectful maternity care and perceptions of respectful maternity care among nursing and midwifery pre-registration students in China: A national cross-sectional study

AIMS

To 1) determine the prevalence and types of disrespectful maternity care witnessed by students; 2) describe students' perceptions of respectful maternity care and associated factors; and 3) investigate whether witnessing disrespectful care influences their perceptions of respectful maternity care.

BACKGROUND

Limited evidence exists about nursing and midwifery students' perceptions of respectful maternity care and prevalence of disrespectful maternity care in China. Understanding students' perceptions can inform pre-registration curricula and clinical practice programs, promoting the implementation of respectful maternity care.

DESIGN

An exploratory national online survey was conducted.

METHODS

Data were analysed using bivariate analysis and multi-factor analysis of variance.

RESULTS

Among 733 students, positive perceptions towards respectful maternity care were common. Approximately one-fifth witnessed disrespect, with physical violence, lack of communication and untimely care most frequently reported. A better understanding of respectful maternity care was associated with female students of Han ethnicity, majoring in midwifery, undertaking a longer internship/practicum and reporting fewer instances of observed disrespect. Although students reported positive perceptions of respectful maternity care, inadequate understanding was evident. Incorporating relevant content about respectful care into the curriculum is suggested. Reducing students' exposure to disrespectful maternity care may ensure that certain forms of disrespect or abuse do not become normalized among students. This requires system-level efforts to create a safe and supportive working environment for maternity health providers.

CONCLUSION

To promote respectful maternity care in China, system-level changes are warranted. Respectful maternity care needs to be essential content in pre-registration midwifery and nursing curricula. Encouraging students to identify poor practice and discuss good practice in a safe learning environment is warranted.

Experienced disrespect & abuse during childbirth and associated birth characteristics: a cross-sectional survey in the Netherlands

BACKGROUND

Experiencing upsetting disrespect and abuse (D&A) during labour and birth negatively affects women's birth experiences. Knowing in what circumstances of birth women experience upsetting situations of D&A can create general awareness and help healthcare providers judge the need for extra attention in their care to help reduce these experiences. However, little is known about how different birth characteristics relate to the experience of D&A. Previous studies showed differences in birth experiences and experienced D&A between primiparous and multiparous women. This study explores, stratified for parity, (1) how often D&A are experienced in the Netherlands and are considered upsetting, and (2) which birth characteristics are associated with these upsetting experiences of D&A.

METHODS

For this cross-sectional study, an online questionnaire was set up and disseminated among women over 16 years of age who gave birth in the Netherlands between 2015 and 2020. D&A was divided into seven categories: emotional pressure, unfriendly behaviour/verbal abuse, use of force/physical violence, communication issues, lack of support, lack of consent and discrimination. Stratified for parity, univariable and multivariable logistic regression analyses were performed to examine which birth characteristics were associated with the upsetting experiences of different categories of D&A.

RESULTS

Of all 11,520 women included in this study, 45.1% of primiparous and 27.0% of multiparous women reported at least one upsetting experience of D&A. Lack of consent was reported most frequently, followed by communication issues. For both primiparous and multiparous women, especially transfer from midwife-led to obstetrician-led care, giving birth in a hospital, assisted vaginal birth, and unplanned cesarean section were important factors that increased the odds of experiencing upsetting situations of D&A. Among primiparous women, the use of medical pain relief was also associated with upsetting experiences of D&A.

CONCLUSION

A significant number of women experience upsetting disrespectful and abusive care during birth, particularly when medical interventions are needed after the onset of labour, when care is transferred during birth, and when birth takes place in a hospital. This study emphasizes the need for improving quality of verbal and non-verbal communication, support and adequate decision-making and consent procedures, especially before, during, and after the situations of birth that are associated with D&A.

Factors Associated with Obstetric Violence Implicated in the Development of Postpartum Depression and Post-Traumatic Stress Disorder: A Systematic Review

Postpartum depression (PPD) and post-traumatic stress disorder (PTSD) continue to be prevalent, and disabling women with mental disorders and obstetric violence (OV) may be a trigger for them, particularly during maternity. We aimed to analyze the association between manifestations of OV with the development of PPD and PTSD during pregnancy, childbirth, and postpartum. This systematic review was based on the PRISMA 2020 statement and explored original articles published between 2012 and 2022. A total of 21 articles were included in the analysis, and bias was assessed by the Effective Public Health Practice Project's Quality Assessment Tool. The highest rate of PPD symptoms appeared in women under 20 years old, multiparous, and with low education levels. The higher PTSD ratio was present in women under 35 years, primiparous, and with secondary studies. The mode of labor (instrumental or C-section) was identified as a major risk factor of PPD, being mediator variables of the informal coercion of health professionals and dissatisfaction with newborn healthcare. Instead, partner support during labor and high satisfaction with healthcare during birth were protective factors. Regarding PTSD, the mode of labor, several perineal tears, and the Kristeller technique were risk factors, and loss of autonomy and coercion modulated PTSD symptomatology. The protective factors for PTSD were respect for the labor plan, adequate communication with health professionals, social support during labor, and the skin-to-skin procedure. This systematic review provides evidence that OV contributes to PPD and PTSD, being important in developing standardized tools to prevent it. This study recommends changes in maternal healthcare policies, such as individualized healthcare assistance, humanized pregnancy protocols, and women's mental health follow-up, and improvements in the methodological quality of future research.