Categories of mistreatment experienced by women.

As participants shared their expectations and positive experiences with healthcare providers and facilities, the topic of mistreatment emerged spontaneously. Participants described the negative experiences they had encountered, witnessed, or heard about, either secondary to interpersonal abuse or as a lack of quality of care during the care process, as presented accordingly in the following sections.

Interpersonal abuses.

Physical abuse. Women participants raised concerns about physical abuse, describing instances where they had observed healthcare providers resorted to hitting women during childbirth due to perceived non-compliance. Participants also highlighted encountering painful procedures as a result of receiving pain-relieving analgesics or anaesthesia, as well as forceful shoving. While sharing her negative experience, a 20-year-old woman described the behaviour of a healthcare provider who assisted in her birth, stating, “She hit my thighs” and “tossed me back and forth.”.

“When she assisted with my birth, she hit my thighs with her hands and tossed me back and forth on the bed. She had the practice students take turns watching me. She told me that my baby was distressed and cut my body [episiotomy]. But she got up and moved away from me; she didn’t seem to be trying to save my distressed baby. … she stepped away from me and said, ‘Finish screaming first!’.” [IDI-WP-08]

Furthermore, instances of forceful pushing, hitting, or pinching with forceps during the second stage of labour were reported, either from personal experience or witnessing another woman being hit. One participant stated, “They hit you with scissors” and “pinch you,” and mentioned that she had personally experienced being struck by a healthcare provider [IDI-WP-06].

Even when it might not be intended to cause harm, forceful pushing and aggressively placing a woman’s legs apart have been reported in situations where a woman did not comply with the orders given by health care providers. When asked if she had experienced anger or any physical aggression from healthcare providers, one participant described the situation as follows:

“If you scream or try to lift your legs from where they have positioned them, they will forcefully push your legs back down. This was clearly obvious.” [IDI-WP-02]

Lack of provision of local anaesthetic during perineal incision for episiotomy, as well as the omission of other forms of pain-relieving agents during instrumental birth and uterine wiping, were reported to cause excruciating pain and discomfort for the women undergoing these procedures. Women who experienced such incidents suggested providers justified carrying out these painful procedures as a means to prevent the complications and fear of being responsible for poor outcomes, as witnessed in the underneath quote:

“The experience of restitching after the birth was very painful…She tried to clean me up, going in and out with her hands. This is what I still find troubling. The pain was intense when she reached into my sensitive womb.’” [IDI-WP-03]

In addition to their personal experiences, some women also witnessed other women being physically abused. One woman described observing another woman being hit because she was tired and was unable to find the energy to push during childbirth:

“I witnessed them hitting another labouring woman at my side, but not me. … I saw her being beaten because she could not progress.” [IDI-WP-02]

Verbal abuse. Women detailed experiencing various forms of verbal abuse, including scolding, threatening, mockery, blame, disavowals, and other insulting remarks from health care providers and other supportive staff in the facility. They described enduring such verbal abuses throughout their stay in the healthcare facility, beginning from their initial visit for antenatal care for some women and often during labour at the time of birth. For instance, one woman reported being scolded, “You are not even showing!” when she first visited the hospital and then mentioned having to leave the hospital in a disappointed mood.

Participants frequently also mentioned being yelled at in derogatory terms, which they described as making them feel unwelcome. One mother described the unsympathetic and insensitive behaviour of a healthcare provider during labour, stating:

“My labour pain gets severe, and my husband came and held me up… ‘What! Why are you hanging on to her? Let her go. Is she the only one experiencing labour pain!’ said one provider to my husband as he supported me while I was in labour pain. Because it was my first time, I did not know how to handle the pain. After that, they became four [providers], and they said, ‘Her labour is not that severe; she does not require a bed,’ as they stood beside me, adding, ‘Is she superior to the rest? Why did the doctor assign her a bed?’ " [IDI-WP-01]

Another primiparous mother shared her experience of being scolded mockingly throughout her birthing process, including targeted personal comments related to her appearance. She also talked about how her childbirth experience lacked informative support. Instead of receiving gentle and professional guidance, the healthcare providers were aggressive, and their communication style felt like yelling, which only added to the woman’s distress during labour, making the situation “quite worrisome.”

“Right from the beginning, you approach the situation[labour] with a sense of anxiety. When the person working there shows anger, it becomes quite worrisome. Uhm…they express their scolds loudly, telling you not to shout and to push quietly. Throughout my birth, I heard her saying, "The baby is small, that’s all she was struggling for." [IDI-WP-02]

Health facilities, particularly hospitals, are sometimes overcrowded, and there may be insufficient resources to accommodate them. In these situations, women have reported experiencing being yelled at, feeling ignored, and receiving negative verbal responses when requesting post-natal beds. One woman recalled staying on the birthing couch throughout the night after giving birth and only being able to get up in the morning. When they asked for a bed, the healthcare providers responded saying:

‘There are no beds; Should I give birth to it for you?’.” [IDI-WP-10]

Another form of verbal abuse reported by women includes being threatened and blamed for any negative outcomes that have occurred or were feared to be possible. These incidents were observed when women failed to cooperate with healthcare providers, indicating a lack of responsibility for any potential complications and depicting the provider’s attitude as ‘passing the buck’. For instance, one woman mentioned that she was told that if anything happened to her, they would not be liable. So, she needed to endure the pain and follow the provider’s instructions:

“. When I pleaded, ‘Please, it is painful,” she responded, ‘Then sign a release so I won’t be held responsible if you face any issues.’… I just watched. I wanted it to be over.” [IDI-WP-03]

Another woman also described such experience as follows:

“There are times when they say, ‘Spread your legs,’ and they purposely scold you even when you ask the right thing …and I take these all as serious problems.” [IDI-WP-04]

A mother who had lost her previous baby a few hours after birth described the situation, recalling her experience. She recounted how healthcare providers blamed her for her baby’s feeding issues and discharged her without properly assessing the newborn’s condition. While describing the situation she faced during the loss of her previous baby, she recounted it as follows:

“… when we informed them about the baby’s difficulty in sucking, one of the healthcare providers there came and inserted her finger into the baby’s mouth and said, ‘The baby is healthy, but it is you who refused to breastfeed.’ Afterwards, they asked us to leave… they discharged us even though we informed them that the baby was not breastfeeding. They said, ‘Unless you have refused to give her, the baby is healthy and can latch.’ She never had a proper latch and never breastfed.” [IDI-WP-06]

Stigma and discrimination. Several women reported feeling discriminated against or receiving a lower level of attention compared to others. One woman reported perceiving discrimination when an attendant provided unequal care, favouring a non-labouring woman over those in distressing labour. She expressed frustration and concern over this unequal treatment, suggesting the reason for the preferential care might be related to personal connection or the role played by woman’s notability. This differential treatment left the participant feeling disappointed and frustrated:

“I wanted to raise the issue of treating people unequally… I saw a nurse sitting next to a woman … cared well. I wished for such care. I know that person, maybe she is a famous person. While another mother was screaming in labour, the nurse was sitting and chatting with that woman without enquiring what was happening with the other woman screaming‥” [IDI-WP-02]

In relation to overcrowding in the facility, women reported that healthcare providers controlled and restricted birth companions in the labour and birthing ward but that this rule was applied inconsistently. Partiality in enforcing rules, possibly due to familiarity between clients and staff or other factors, left some women feeling neglected, helpless, unsupported, and confused during childbirth. One woman felt isolated and believed she was treated differently when it came to having a birth companion and described that the health care provider did not consistently enforce the same rule for everyone; they allow birth companions for some while they send other birth companions away.

“While sending out my companion, she did not do this for all… She would go and help the other woman in labour, saying, ‘Cheer up, be strong.’ I don’t know if they knew each other or not. She even called someone for her, her companions, to help her, and they would reach out to her, offering encouragement. She was very helpful for her, but for me…. puu, nope.” [IDI-WP-08]

Mistreatment in the process of care.

The mistreatment experienced by women in this category is not solely attributed to the individual behaviours of healthcare providers. Instead, these instances have emerged within the care process, stemming from compounded issues involving healthcare providers and the facility—in the lack of quality care perspective. These issues include violations of privacy, non-consented care, lack of confidentiality, neglect, abandonment, and poor communication. Delays in receiving midwifery care, lack of attention and breaches of professional standards of care led to some women enduring life-threatening situations, as depicted below:

“They discharged me while I was still bleeding, before my condition had stabilised, and before I had changed my clothes. I gave birth at 8 o’clock, and I was discharged at 12 o’clock. They mentioned they would provide the necessary items like vaccination for the baby immediately after birth. However, later, as they saw me still lying there, they asked, "What are you doing here for so long?" So, I just left at that point.” [IDI-WP-05]

Violation of privacy, confidentiality, and preferences. Another set of issues related to the structural arrangements of the labour and birthing unit, as well as the attitude of the health care providers, pertained to the failure to meet professional standards of care. This included the violation of privacy, confidentiality and the inability of women to participate in the decisions being made about their care. One woman, despite describing the service she received as ’good,’ highlighted the lack of privacy and consented care during examinations:

“At the time they examined me, there were no curtains or screens. The way they accommodate you is good, but there was no privacy. When they examine my cervix, they remain silent, and no one asks you for your consent or preferences.” [IDI-WP-04]

This lack of consent was not an isolated incident and was often accompanied by practices that violated the privacy of women during labour or childbirth. Associated with the uncomfortable setup of the health care facility, such as the absence of curtains or screens and private rooms, there were reports of multiple people being present in a single small labour attendance unit. When a woman was asked if healthcare providers obtained her consent or provided an explanation before performing an episiotomy, she described that it was not the case and mentioned hearing the sound of cutting her body without explanation:

"…when I was giving birth … I recall being instructed to ’push … push.’ I believe I was able to push the baby out, but while I was following their directions, they made an incision in my body, I just heard the ’snip’ sound while they cut my body without saying anything to me. …They did not ask me anything of the sort. Around seven or eight apprenticeship students were standing around me, observing. She did not say anything to me–no explanation, no mention of doing stitches, and no pain relief medication.” [IDI-WP-03]

Besides the violation of privacy and confidentiality, women also reported unnecessary repeated examinations along with poor communication. One woman, while explaining that she had never experienced such mistreatment in her previous births, stated that several students repeatedly performed vaginal examinations on her without offering any explanations, all in front of the people present in the room.

"They repeatedly examined me without saying anything. Even many of the students who were practising there have also seen me right in front of the people, in front of everyone who came to visit other birthing women. There were many people present, and many women were lying; in front of everybody, they performed examination [vaginal examination]." [IDI-WP-05]

Neglect and abandonment. Feeling neglected and abandoned was identified as additional forms of mistreatment described by women during their care, attributed either to individual healthcare providers’ attitudes or facility conditions. Some women emphasised that certain providers would occasionally ignore them, potentially worsening the women’s conditions, which they reported as ’feeling left alone’, ’ignored’, ’neglected’ and ’abandoned’, not only when they were alone but also when healthcare providers were present, expressing a sense of inattentive observation or using the woman’s unborn baby as a tool to gain compliance. One woman shared her experience:

“… She turned to me and said, ‘Your baby is dying, be strong.’ But she moved away and started sitting. She told me that my fetus was distressed and cut my body [episiotomy]. But she got up and moved away from me, she did not seem to be trying to save my distressed baby.” [IDI-WP-08]

When the provider who initially admitted the mother left her alone, other providers often claimed that it was not their responsibility. This abandonment or lack of attention during labour led to women giving birth by themselves in the same place where they were labouring:

"I gave birth on the same bed I was lying on when I first arrived, and they did not even notice when I gave birth. I gave birth to my baby on my own pyjamas… It was not until the people in the room shouted, ’Please, she’s giving birth here,’ that the healthcare providers rushed in. When they arrived, I had already given birth right there. My child had water [amniotic fluid] in his nose. He even still struggles to breathe." [IDI-WP-05]

The participants also reported instances where labouring mothers were intentionally abandoned, ignored, or neglected by the providers. One woman recounted an experience where she felt abandoned by a group of providers due to hierarchical issues among them. She mentioned that one provider prevented others from examining her during labour, insisting that she wanted to be examined only by a specialist doctor, contrary to her actual desire. She recalled it as:

“When another doctor came to examine me, one of them said, ‘Leave her alone; there is no one other than the specialist doctor who checks her status.’ She did this at least to two, and then they left me…while they came and assessed other labouring women repeatedly, they just ignored me.” [IDI-WP-01]

Exposed to unfair fees. Maternal and child health services in public facilities in Ethiopia are generally exempt from charges. However, some women have reported being unexpectedly subjected to outsourced fees. One woman complained that she was asked to purchase medications but did not receive them.

“Initially, they sent my husband to buy medication. After he made the purchase, they took it away and never returned it. We bought medication for 500 Ethiopian Birr and left without receiving it. They repeatedly asked him to bring medicine.” [IDI-WP-05]

Ontogenic: Individual-level factors.

Issues at the individual level that the women thought to be influential in the occurrence of mistreatment include exhaustion, burnout, negligence, negative attitudes, and fear of poor outcomes, among others. One participant, reflecting on her own experiences during childbirth, mentioned that a "lack of empathy" and "attitude" might have contributed to those behaviours rather than increased workloads. She also recognised that there were respectful providers among them when asked about the aspects contributing to these negative behaviours.

"I am not sure why they would behave like that. They might mention being busy, …umm…but you see only a few patients in the hospital when they themselves are being crowded. If it were really crowded, you would understand …I think it is a lack of empathy…Yes, their attitude is somewhat lacking. However, there are some who genuinely care for people and provide dedicated service. There are individuals who have strong desire among them." [IDI-WP-05]

On top of the impacted empathy and lacking attitude, exhaustion leading to despair was also perceived as one of the underlying reasons for mistreatment by other women. Participants brought up the issue of exhaustion, which may affect the confidence and satisfaction that providers have in their service provision and their professional outlook when dealing with individuals of various personalities:

"I think it is because they work there every day, and it makes them exhausted. They, the workers, seem desperate. I do not think they find satisfaction in performing their skilled tasks. Uhm … it looks like they lose their way and end up there in despair due to the intense experiences they go through. I wonder if these experiences with women could affect them and lead to improper behaviours. Maybe these lead them to be careless." [IDI-WP-03]

Negligence arising from carelessness was also mentioned as a reason behind the behaviour of some providers and leading to mistreatment. Such behaviours overall are described as a loss of responsibility and accountability.

"I would say the problem lies in the lack of accountability. It is not just the health care professionals but everyone working in the system who needs to take responsibility. I think they have forgotten their responsibilities. …. Even those who are passionate about their job and understand the excitement of a new life coming into the world seem to have forgotten this." [IDI-WP-06]

Microsystem: Interpersonal.

Interpersonal issues, whether between women and healthcare providers or among professionals themselves, were identified as contributing to negative experiences for women in healthcare facilities. One of these interpersonal issues contributing to mistreatment was poor communication during interactions. For instance, a woman who felt impatiently treated by a midwife [the women mostly call/see midwives as nurses] during a labour examination reported that misunderstandings between her attendants and healthcare providers resulted in her being ignored by the care team. She recounted the midwife’s nervousness as:

“It was my mother who accompanied me to the labour ward initially; after we arrived there, I was sitting, and my mother was standing. Then they asked us…’what was your case?’ my mother did not hear what they asked and replied, ‘uhh, what did you say?’ to the nurse who asked us because she didn’t hear what the nurse asked as she was facing toward me, and then the nurse said ‘what does it mean to say ’uhh’, just leave the room and stay outside’, while getting nervous [laughter…].” [IDI-WP-01]

Mesosystem: Health facility-related issues.

Various issues related to health facility conditions, ranging from health facility types, lack of conducive environment, facility-specific policies, crowdedness, delay and resource-related issues, were perceived by participants to act as a conduit for the occurrence of mistreatment. Some women raised concerns related to health facility policy, including a lack of an adequate number of providers during holidays, poor regulation and control from the leaders, and lack of a redress system, which all result in mistreatment. When recounting the way providers hand over cases, one woman said she was left alone because the one who was caring for her left without reporting to others:

“I got tired of asking for help. Those who were supposed to assist me just disappeared, abandoning me, let alone helping me without my consent. Others would say, ‘She’s not mine; she belongs to Sister ’X’, did she go off?’ by calling her name. They did come after many requests for help… I believe they swapped shifts, maybe she left during that time.” [IDI-WP-02]

A woman who believed that addressing women’s complaints could enhance the health facility’s shortcomings noticed a lack of initiatives aimed at assessing these weaknesses and striving for improvement. She observed a deficiency in feedback mechanisms from both health centres and the hospitals’ leadership, which could have been used to address facility weaknesses in providing care.

“The organisation should address community complaints. I think that covers it. Unfortunately, in many places, there seems to be a lack of follow-up, and it appears that the leadership has forgotten its responsibilities. I haven’t come across that. I’ve never seen any inquiries about whether we were receiving proper service or not, neither in the health centre nor in the hospital.” [IDI-WP-06]

Lack of readiness of health centres in terms of resources was also cited to enhance occurrences of mistreatment by leading women to undermine services provided in health centres and leading them to opt for hospitals, resulting in the crowdedness of the hospital.

“There are some differences between the conditions at the health centre and the hospital…It is difficult to say there is follow-up at the health centre; the hospital is more equipped. It was only iron that you get from the health centre.” [IDI-WP-04]

Exosystem: Health system.

Several issues stemming from different levels of the health system influence the services offered to women by healthcare providers and facilities. These concerns are connected to the foundational aspects of quality care within the healthcare system, encompassing both organisational and physical elements that shape the care process. Overcrowding in health facilities, conflict arising because of hierarchy among providers, fear of blame, disabled functionality of the referral system, culture of blame, and lack of accountability among providers were highlighted to drive mistreatment.

Power dynamics among providers marked by poor coordination, a lack of teamwork and respect often leave women feeling isolated and abandoned. These issues reflect deep-rooted problems in interdisciplinary collaboration, shaped by professional training norms and hierarchical positions, such as those between doctors and midwives:

“… the providers became four, and they said, ‘Her labour is not that much, and it does not necessitate a bed.’ As they stood beside me, they added, ‘Is she superior to the rest? Why did the doctor assign her a bed?’” [IDI-WP-01]

The fear of being held responsible for any negative outcomes that women and newborn babies might experience is found to influence how healthcare providers behave. Some women reported being threatened by professionals, who warned they would not be held responsible if anything went wrong with them or their babies. This behaviour reflects broader systemic issues, where the focus is placed on avoiding adverse outcomes, potentially at the expense of the quality of care provided. This issue is highlighted in a quote from a woman who underwent a painful procedure:

“… There’s a saying from providers, "If something happens to the child, it’s not on me." [IDI-WP-04]

Macrosystem: Society level.

This category presents how societal factors, such as gender norms, beliefs, and community attitudes, influence how health facilities and healthcare providers deliver services. Structural gender inequality in society leads to the tolerance of violence against women. Consequently, mistreatment of women becomes normalised within health facilities, stemming from the belief that ’health care providers have the right to chastise women’ during childbirth to ensure compliance with the birthing process. These circumstances render women in a passive role, disempowered from speaking out against abusive behaviours during service reception. Such normalisation and disempowerment of women could be seen when one woman recounted an incident where another woman was bitten and expressed the futility of lodging complaints by stating, ’no one hears you’:

“…may be the hospitals are different, but in another hospital, I saw two midwives beating a woman who was bleeding while a tube was in her body, I saw it with my own eyes… when I witnessed those two midwives beating that woman, I wanted to retaliate physically if I could … if I were in that situation, I do not think I would stay quiet…What else can you do? No one hears you.” [IDI-WP-05]

Insecurity within the community due to ongoing unrest was another contextual issue found to have a substantial impact on the services tailored for women. This included restricted access and the reluctance of service providers, ultimately disrupting the referral system linking lower-tier facilities with higher ones. Reflecting on the challenges amplifying the constraints of rural health centres and health posts, a woman highlighted the scarcity of ambulances and instances where health facilities remained inaccessible despite undertaking lengthy journeys to reach semi-urban district facilities.

“In our village? … [yes …], the problem is the one I mentioned to you now. If a pregnant woman goes into labour and if one calls for an ambulance, they’ll tell you, ‘The ambulance was burned.’ Even for the labouring woman herself, if they find a private car, they pay and take her to the facilities.” [IDI-WP-07]