title: "By slapping their laps, the patient will know that you truly care for her": A qualitative study on social norms and acceptability of the mistreatment of women during childbirth in Abuja, Nigeria.
abstract: BACKGROUND
  Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth.
  
  
  METHODS
  Two facilities were identified in Abuja, Nigeria. Qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) were used with a purposive sample of women, midwives, doctors and administrators. Participants were presented with four scenarios of mistreatment during childbirth: slapping, verbal abuse, refusing to help the woman and physical restraint. Thematic analysis was used to synthesize findings, which were interpreted within the study context and an existing typology of mistreatment during childbirth.
  
  
  RESULTS
  Eighty-four IDIs and 4 FGDs are included in this analysis. Participants reported witnessing and experiencing mistreatment during childbirth, including slapping, physical restraint to a delivery bed, shouting, intimidation, and threats of physical abuse or poor health outcomes. Some women and providers considered each of the four scenarios as mistreatment. Others viewed these scenarios as appropriate and acceptable measures to gain compliance from the woman and ensure a good outcome for the baby. Women and providers blamed a woman's "disobedience" and "uncooperativeness" during labor for her experience of mistreatment.
  
  
  CONCLUSIONS
  Blaming women for mistreatment parallels the intimate partner violence literature, demonstrating how traditional practices and low status of women potentiate gender inequality. These findings can be used to facilitate dialogue in Nigeria by engaging stakeholders to discuss how to challenge these norms and hold providers accountable for their actions. Until women and their families are able to freely condemn poor quality care in facilities and providers are held accountable for their actions, there will be little incentive to foster change.
authors.affiliation: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe St, Baltimore, MD, USA; UNDP/UNFPA/UNICEF/WHO/WorldBank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Meghan A
authors.initials: MA
authors.lastname: Bohren
authors.affiliation: UNDP/UNFPA/UNICEF/WHO/WorldBank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Vogel
authors.affiliation: UNDP/UNFPA/UNICEF/WHO/WorldBank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Özge
authors.initials: Ö
authors.lastname: Tunçalp
authors.affiliation: Departmentof Obstetrics & Gynaecology, National Institute of Maternal & Child Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
authors.forename: Bukola
authors.initials: B
authors.lastname: Fawole
authors.affiliation: Departmentof Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
authors.forename: Musibau A
authors.initials: MA
authors.lastname: Titiloye
authors.affiliation: Departmentof Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria.
authors.forename: Akinpelu Olanrewaju
authors.initials: AO
authors.lastname: Olutayo
authors.affiliation: Departmentof Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
authors.forename: Agnes A
authors.initials: AA
authors.lastname: Oyeniran
authors.affiliation: Departmentof Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
authors.forename: Modupe
authors.initials: M
authors.lastname: Ogunlade
authors.affiliation: Departmentof Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
authors.forename: Loveth
authors.initials: L
authors.lastname: Metiboba
authors.affiliation: Departmentof Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria.
authors.forename: Olubunmi R
authors.initials: OR
authors.lastname: Osunsan
authors.affiliation: Nyanya General Hospital, Abuja, Federal Capital Territory, Nigeria.
authors.forename: Hadiza A
authors.initials: HA
authors.lastname: Idris
authors.affiliation: Maitama District Hospital, Abuja, Federal Capital Territory, Nigeria.
authors.forename: Francis E
authors.initials: FE
authors.lastname: Alu
authors.affiliation: UNDP/UNFPA/UNICEF/WHO/WorldBank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Olufemi T
authors.initials: OT
authors.lastname: Oladapo
authors.affiliation: UNDP/UNFPA/UNICEF/WHO/WorldBank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: A Metin
authors.initials: AM
authors.lastname: Gülmezoglu
authors.affiliation: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe St, Baltimore, MD, USA; UNDP/UNFPA/UNICEF/WHO/WorldBank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: Michelle J
authors.initials: MJ
authors.lastname: Hindin
keywords: ACASI, audio computer assisted self-interview; COREQ, consolidated criteria for reporting qualitative research; Childbirth; DHS, Demographic and Health Survey; FGD, focus group discussion; HRP, World Health Organization Human Reproduction Programme; IDI, in-depth interview; IPV, intimate partner violence; LMIC, low- and middle-income country; Maternal health; Mistreatment; Nigeria; Qualitative research; Quality of care; RP2, Review Panel on Research Projects; SDG, Sustainable Development Goals; USAID, United States Agency for International Development