Bunmi is in labour with her first child and has just arrived at her local district hospital. She is nervous, and doesn't know what to expect. Her mother accompanied her to the hospital but is barred from entering the maternity ward. Bunmi is effectively left on her own to go through labour and birth with strangers.

During Bunmi's first interaction with the midwife, she receives an abrupt vaginal examination to check how her labour is progressing. But the midwife doesn't ask her permission, tell her why she is conducting the exam, or even tell her what she found. She just does it. Bunmi is then moved straight to the delivery room where there are four beds with stirrups and no sheets or curtains. She can see and hear other women pushing their babies out. Her heart races with fear.

The midwife approaches and yells, "It's time for you to push now or you will kill your baby! Don't cry out. When your husband was doing it to you, you enjoyed it, but now you are just disturbing us with your noise." The midwife slaps Bunmi repeatedly across the thigh, ostensibly to "help" her push.

While Bunmi is an amalgam of the sorts of experiences our research team witnessed and recorded, it is nevertheless an accurate reflection of what the reality of childbirth is for millions of women in many low- and middle-income countries around the world.

Our new evidence from a World Health Organization (WHO) study published in The Lancet of childbirth experiences in Ghana, Guinea, Nigeria and Myanmar found that more than one-third of women were mistreated during childbirth in health facilities.

The study involved independent researchers observing more than 2000 women throughout their labour and childbirth, as well as surveying over 2,600 women up to eight weeks after their child was born. Of the women we observed, nearly 42 per cent experienced physical abuse, verbal abuse or stigma and discrimination, while 35 per cent of the women we surveyed reported such abuse.

We found that physical and verbal abuse peaked between 30 minutes before birth though to 15 minutes after birth. Women were nearly 12 times more likely to experience physical abuse and seven times more likely to experience verbal abuse within 15-minutes before birth, compared to one-hour before birth.

We also found that younger, less educated women were most at risk, suggesting inequalities in how different women are treated during childbirth. Younger women aged 19 or less were almost twice more likely to experience physical abuse than older women. Younger women with no education were almost four times more likely to experience verbal abuse.

Among the women we observed, 59 per cent didn't consent to their first vaginal examination. Younger, unmarried women were nearly five times more likely to have an unconsented vaginal examination.

Women also reported in the surveys that surgical and medical procedures were often conducted without their consent – 11 per cent of caesarean sections, 56 per cent of episiotomies (surgical cutting of the vagina), and 27 per cent of induced labours were conducted without an adequate informed consent process.

We observed similar numbers of women who did not consent to procedures: 13 per cent of caesarean sections, and 75 per cent of episiotomies.

And shockingly, nearly 5 per cent of women gave birth in the health facility with no healthcare provider present.

Our study built on the results from a systematic review I'd led, which developed a classification of what behaviours constituted mistreatment during childbirth, based on 65 earlier studies conducted in 34 countries.

The review identified mistreatment as primarily physical and verbal abuse, stigma and discrimination, as well as failure to meet professional standards of care, poor rapport between women and providers, inadequate health conditions and capacity constraints.

These challenges vary across settings but can include insufficient staffing, poor supervisory structures, poor physical conditions of the health facilities, and power dynamics that systematically disempower women.

Professional associations play a key role in supporting maternity providers and safeguarding their rights. For example, midwives are the backbone of maternity services in many countries, but they often work in disempowering environments.

Their contributions may not be adequately recognised, and they may be disrespected and unsupported by their supervisors.

Midwives are predominantly women who work in their own communities and face the same challenges other women face: low social status, gender inequality, and gender-based violence.

While it is critical to hold health systems accountable for mistreatment when it does occur, improvements are clearly needed to effectively prevent and respond to these harmful practices. Health systems and healthcare providers must have sufficient resources to provide quality, accessible maternity care that places the woman and her baby at the centre of care.

In 2014, WHO issued a statement on the prevention and elimination of disrespect and abuse during childbirth, positioning the issue as a violation of rights and trust between women and healthcare providers. Likewise, the 2018 WHO recommendations on care in childbirth highlight the importance of woman-centred maternity care.

These recommendations use a human-rights based approach to advocate for the provision of respectful maternity care that maintains women's dignity, privacy and confidentiality, enables informed choice and continuous support, and ensures freedom from mistreatment.

So where do we go from here? Substantial progress has been made on listening to and understanding women's poor experiences of care across many different contexts. However, further research is needed to understand how institutional structures and processes can be reorganised to put women and their babies at the centre of care.

Understanding how structural drivers influence how women are treated during childbirth, including gender and social inequalities, power imbalances, normalisation of poor practices, and judgements about women's sexuality, are critical.

Promoting woman-centred maternity care and preventing mistreatment during childbirth can only be achieved through inclusive and equitable processes engaging both communities and healthcare providers. While limited evidence exists on effective interventions, possible strategies include:

• Redesigning labour wards to allow for privacy and labour companionship
  
• Providing skills-building exercises for effective communication and informed consent procedures
  
• Teaching providers stress-coping mechanisms
  
• Ensuring that healthcare providers are empowered and supported through supervisory structures; that workloads are manageable; and that remuneration is adequate
  

The findings of our study should inform policies and programmes to ensure that all women have positive pregnancy and childbirth experiences and are supported by empowered healthcare providers within well-functioning health systems.

Dr Bohren carried out this work as part of a joint appointment with the Department of Reproductive Health and Research at the World Health Organization.

This research was funded by the United States Agency for International Development (USAID) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, WHO.

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