What drives providers to disrespect and abuse women during childbirth?

Disrespect and abuse during childbirth are a violation of women’s human rights. Women deserve care that maintains their dignity, ensures their privacy and confidentiality and is free from mistreatment and discrimination. Given that women are the target of this abuse, most research has rightly focused on their perspectives. However, it’s also essential to get a better understanding of what drives providers toward this behavior. New Bixby research uses interviews with providers in 18 facilities in rural Kenya to examine drivers of disrespect and abuse during maternity care.

Although most providers reported that women are mostly treated with respect, some acknowledged that verbal and physical abuse and lack of privacy and confidentiality occur. The research team identified several drivers of this behavior:

  • Perceiving women as difficult or uncooperative. The most common reason given for abuse was that they “had to do it” to save the baby when the woman was uncooperative or difficult. Examples of what made women “difficult” included not following instructions, refusing exams or aspects of care, screaming too much, wanting to deliver on the floor or being disrespectful to providers.
  • Stressful work conditions and burnout. High workload due to staff shortage, lack of essential supplies and medicines, women presenting for labor without the recommended items, disrespect from others, language barriers, women not cooperating and fear of maternal or newborn death all contributed to provider stress and burnout.
  • Facility culture and accountability. Providers were more likely to engage in behaviors they felt were acceptable in their facility. Unacceptable behaviors might be punished if someone was willing to stand up against them.
  • Poor infrastructure and lack of supplies and medications. It was sometimes difficult to maintain women’s privacy and confidentiality because of small labor wards and lack of privacy screens. Women had to bring their own supplies like sanitary pads and detergents, and those who didn’t bring their own sheets were sometimes left uncovered.
  • Provider attitudes. Relatively few providers admitted to their own responsibility, but a few acknowledged that disrespect and abuse were sometimes due to provider attitudes and temperament.
  • Provider bias. Implicit and explicit biases appeared to promote favoritism toward certain groups and discrimination against others. Providers acknowledged there was differential treatment by personal connections, wealth, social status, education, empowerment, age and ethnic affiliation.
  • Provider training and women’s empowerment. Providers who were more aware of women’s rights had changed their behaviors. Some said they had stopped pinching women since going to training and, as one person put it, “left the barbaric old way of nursing.” Lack of knowledge and skills in alternative ways to deal with difficult situations, as well as unreasonable expectations of women in labor, appeared to be key reasons for mistreatment.

These findings suggest that disrespect and abuse are driven by difficult situations—real or perceived—in a health system and a sociocultural environment that facilitates them. Some women may be difficult for providers to manage, but a woman being difficult alone would probably not lead to abuse without a provider who is stressed, overwhelmed and helpless, but who had power over the woman and works in a culture that tolerates abuse as a means of gaining compliance. Interventions to address this need to tackle multiple intersecting factors, empowering providers with the skills to manage difficult situations and addressing their biases, improving the work environment to reduce stress as well as changing the culture of facilities and health systems.