EDITORIAL
Disrespect and Abuse of Women During
Childbirth: A Significant Factor in the Efforts
to Reduce Maternal and Perinatal Morbidity
and Mortality
A significant factor in the efforts to reduce maternal
and perinatal morbidity and mortality across the globe
has been to encourage women to give birth in health
care facilities (Vogel, Bohren, Tuncalp, Oladapo, &
Gulmezoglu, in press). However, although the rates of
facility-based childbirth grew, it also gave greater exposure to the fact that many women are subjected to disrespect and mistreatment during childbirth; underscoring
that abuse during childbirth is a wide-spread global issue.
It negatively impacts a woman’s access to health services
and the quality and effectiveness of her care (d’Oliveira,
Diniz, & Schraiber, 2002). Violence perpetrated against
women during childbirth is often about power and
control; controlling women during birth to get them
to accept unnecessary treatments, interventions, and
surgery. The abuse is not always overt, and it may
encompass subtle humiliation, or abandonment of care
in addition to the more overt physical and verbal abuse
(Bowser & Hill, 2010). Sadly, much of the abuse birthing
women experience is committed by the clinicians providing their care, and all too often the abusive behaviors
are normalized and tolerated by other clinicians who
observe the mistreatment as well as by the women who
are at the receiving end of the abuse. It should go without
saying that during childbirth a woman is vulnerable and
therefore she may be afraid to speak up about the abuse
and mistreatment she is experiencing.
Abuse during childbirth may include a lack of
informed consent, misrepresenting medical situations
and the use of threats to coerce women into accepting
unnecessary interventions (Hodges, 2009). In some
instances, the abuse takes the form of physical violence
such as rough vaginal examinations, hitting, slapping,
and cesarean sections without anesthesia, whereby the
clinician discredits the woman’s statements that her
epidural has worn off and she is feeling the pain of the
2
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surgery (Goer, 2010). Too often the result of abuse during pregnancy and childbirth serves as a deterrent to
seeking health care which can adversely affect a woman’s well-being (Mannava, Durrant, Fisher, Chersich,
& Luchters, 2015). The violence inflicted on women
during childbirth can cause severe emotional and psychological trauma resulting in the development of
posttraumatic stress syndrome (PTSD; Goer, 2010). In
a U.S. study of women’s experiences of childbirth, 1 out
of 10 respondents were found to meet all diagnostic criteria for PTSD (DeClercq, Sakala, Corry, & Applebaum,
2006). Violence violates the universal rights of childbearing women (White Ribbon Alliance, 2011).
Violence inflicted on birthing women is, among
other issues, a quality of care issue. Quality care of
mothers and their babies is care that is safe, effective,
timely, efficient, equitable, and people-centered (Vogel
et al., in press). In an effort to decrease maternal morbidity and mortality, there has been a push in many
countries to encourage women to use health facilities
during childbirth so that they have access to skilled
clinicians. However, when clinicians in these facilities
mistreat birthing women, they undermine the woman’s
confidence in the facility and its clinicians. In a survey
of 1,388 women who were discharged from two hospitals in Tanzania, the findings revealed that disrespect
and abusive treatment of women during childbirth was
a significant factor in reducing their confidence in using
health facilities (Kujawski et al., 2015).
Studies that focus on measuring respectful care are
urgently needed. A cross-sectional study that took place
in sub-Saharan Africa focused on the identification of
respectful care and used observations of provider–client
interactions (n 5 2,164) in diverse health facility settings (n 5 6). The findings revealed that although overall most women in the study were treated with dignity
INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 6, Issue 1, 2016
© 2016 Springer Publishing Company, LLC www.springerpub.com
http://dx.doi.org/10.1891/2156-5287.6.1.2
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Editorial 3
and in a supportive manner by their clinicians, some
specific issues of abuse were identified as needing to be
addressed: inadequate interpersonal communication by
some clinicians, abandonment and delays in care such
as a lack of monitoring, inadequate privacy protection,
and in some cases, physical and verbal abuse (Rosen
et al., 2015). The importance of this study cannot be
emphasized enough as it is one of the first to focus on
measuring respectful care by direct observation during
labor and delivery.
The abuse and mistreatment of women during
birth occurs across all socioeconomic and geographic
lines and unfortunately, it has been ongoing for quite
some time. Cruelty in U.S. maternity units was identified in a Ladies Home Journal article in 1958 (Schultz,
1958). This article drew significant attention to the abuse
and mistreatment of birthing women and as a result, it
stimulated several efforts focused on childbirth reform
including the founding of what is now known as Lamaze
International (Goer, 2010). Even though health care
reform in the United States has created national attention
to the problems of escalating cesarean sections and the
overuse of interventions during childbirth, the reality is
that all too often women are still being mistreated and
subjected to abuse during childbirth (Hodges, 2009).
The World Health Organization (WHO) demonstrated a commitment to supporting the rights of
women and their access to safe, timely, respectful care
during childbirth in the development of a statement on
the prevention and elimination of disrespect and abuse
during facility-based childbirth: “Every woman has the
right to the highest attainable standard of health, which
includes the right to dignified, respectful health care”
(WHO, 2014). This statement is endorsed by more
than 90 professional organizations and is available in
more than 15 languages. The statement emphasizes the
rights of every woman to be cared for in a respectful
and dignified manner during childbirth and it also is
a clarion call to the need for more action, discourse,
research, and advocacy by all stakeholders on this issue
(Vogel et al., in press).
The White Ribbon Alliance (WRA) launched a
global campaign in 2011 to promote clear standards for
respectful maternity care (RMC). The WRA worked
with other global organizations to produce a critical consensus document, the RMC Charter: the universal rights
of childbearing women (WRA, 2011). The Charter is
currently available in eight languages and is used as a
tool to educate health workers about maternity care and
human rights (WRA, 2011). The Charter is currently
endorsed by the WHO, the International Federation of
IJC6-1_PTR_A1_002-004.indd 3
Gynecology and Obstetrics, and the International Confederation of Midwives.
The WRA identifies five approaches to RMC that
encompass the universal rights of childbearing women:
1. Promote the right to respectful maternity care.
2. Mobilize communities to demand respectful care.
3. Integrate the RMC Charter into training and standards for health care providers.
4. Support health care providers to deliver respectful
maternity care.
5. Incorporate RMC in national legislation and health
care policy.
Although it is recognized that there have been
great strides in preventing mistreatment during childbirth, the work is not yet finished. We must continue to
advocate for safe and effective care during pregnancy
and childbirth for all women. It is the responsibility of
all members of the maternal health community to “out”
health care workers who subject women to abuse and
mistreatment during pregnancy and birth and report
their actions to the appropriate authority that will assure
that the mistreatment does not continue.
It is also important to appreciate that RMC is
about more than the prevention of mistreatment during childbirth; it is about using appropriate language
and respecting a woman’s culture. It is about assuring
the care provided is safe and equitable and that the
environment is supportive of her needs. It involves good
listening and communication skills and working in collaboration with other health care workers. There is very
little research that identifies for us what comprehensive
RMC encompasses; therefore, there is a great need for
evidence-based research in this area to identify the
interventions that promote respectful high quality care
for women during pregnancy and childbirth.
There are several helpful websites that provide
important information about RMC; thus, the list in the
following text is not exhaustive but will prove useful
to all who are involved in promoting respectful care in
pregnancy:
•International Confederation of Midwives: http://www
.internationalmidwives.org/
•International Federation of Gynaecology and
Obstetrics: http://www.figo.org/
United
States Agency for International Development
•
Translating Research Into Action Project: http://www
.tractionproject.org/sites/default/files/Respectful
_Care_at_Birth_9-20-101_Final.pdf
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4 Editorial
•White Ribbon Alliance: Respectful Maternity
Care: http://whiteribbonalliance.org/campaigns2/
respectful-maternity-care/
•WHO Fact Sheets on Health and Human Rights:
http://www.who.int/mediacentre/factsheets/fs323/en/
Kujawski, S., Mbaruku, G., Freedman, L. P., Ramsey, K.,
Moyo, W., & Kruk, M. E. (2015). Association between
disrespect and abuse during childbirth and women’s
confidence in health facilities in Tanzania. Maternal
and Child Health Journal, 19, 2243–2250. http://dx.doi
.org/10.1007/s10995-015-1743-9
Kerri D. Schuiling
Co-Editor-in-Chief
Dean, School of Nursing
Oakland University
Rochester, MI
Mannava, P., Durrant, K., Fisher, J., Chersich, M., & Luchters, S.
(2015). Attitudes and behaviours of maternal health
care providers in interactions with clients: A systematic review. Globalization and Health, 11, 1–17. http://
dx.doi.org/10.1186/s12992-015-0117-9
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Bowser, D., & Hill, K. (2010). Exploring evidence for disrespect
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DeClercq, E. S., Sakala, C., Corry, M. P., & Applebaum, S.
(2006). Listening to mothers II: Report of the second
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IJC6-1_PTR_A1_002-004.indd 4
Rosen, H., Lynam, P. F., Carr, C., Reis, V., Ricca, J., Bazant, E. S.,
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