title: Manifestations and drivers of mistreatment of women during childbirth in Kenya: implications for measurement and developing interventions.
abstract: Disrespect and abuse or mistreatment of women by health care providers in maternity settings has been identified as a key deterrent to women seeking delivery care. Mistreatment includes physical and verbal abuse, stigma and discrimination, a poor relationship between women and providers and policy and health systems challenges. This paper uses qualitative data to describe mistreatment of women in Kenya.
  
  
  
  Data are drawn from implementation research conducted in 13 facilities and communities. Researchers conducted a range of in-depth interviews with women (n-50) who had given birth in a facility policy makers health managers and providers (n-63); and focus group discussions (19) with women and men living around study facilities. Data were captured on paper and audio tapes, transcribed and translated and exported into Nvivo for analysis. Subsequently we applied a typology of mistreatment which includes first order descriptive themes, second and third-order analytical themes. Final analysis was organized around description of the nature, manifestations and experiences, and factors contributing to mistreatment.
  
  
  
  Women describe: their negative experiences of childbirth; frustration with lack of confidentiality and autonomy; abandonment by the providers, and dirty maternity units. Providers admit to challenges but describe reasons for apparent abuse (slapped on thighs to encourage women to focus on birthing process) and 'detention' is because relatives have abandoned them. Men try to overcome challenges by paying providers to ensure they look after their wives. Drivers of mistreatment are perpetuated by social and gender norms at family and community levels. At facility level, poor managerial oversight, provider demotivation, and lack of equipment and supplies, contribute to a poor experience of care. Weak or non-existent legal redress perpetuate the problem.
  
  
  
  This paper builds on the expanding literature on mistreatment during labour and childbirth -outlining drivers from an individual, family, community, facility and policy level. New frameworks to group the manifestations into themes or components makes it increasingly more focused on specific interventions to promote respectful maternity care. The Kenya findings resonate with budding literature - demonstrating that this is indeed a global issue that needs a global solution.
authors.affiliation: Population Council, 4301 Connecticut Avenue NW Suite 280, Washington DC, USA.
authors.forename: Charlotte E
authors.initials: CE
authors.lastname: Warren
authors.affiliation: Population Council, PO Box 17643 - 00500, Nairobi, Kenya.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Njue
authors.affiliation: Population Council, PO Box 17643 - 00500, Nairobi, Kenya.
authors.forename: Charity
authors.initials: C
authors.lastname: Ndwiga
authors.affiliation: Population Council, PO Box 17643 - 00500, Nairobi, Kenya. tabuya@popcouncil.org.
authors.forename: Timothy
authors.initials: T
authors.lastname: Abuya
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000379:methods / Q000523:psychology*; D005260:Female; D000074386:Gender-Based Violence / Q000523:psychology*; D006282:Health Personnel / Q000523:psychology*; D006801:Humans; D007630:Kenya; D008297:Male; D036801:Parturition / Q000523:psychology*; D011247:Pregnancy; D036301:Qualitative Research; D012938:Social Perception; D057545:Social Stigma
keywords: Childbirth; Disrespect and abuse; Kenya; Mistreatment