Introduction

Childbirth is a transformative event in a woman’s life, ideally a positive and safe experience free of complications, where both mother and baby receive appropriate care. However, evidence indicates that many pregnant women globally face disrespectful and offensive treatment during childbirth, violating their rights and endangering their health [1,2]. To counter this, the concept of humanized maternity care has emerged, emphasizing respect for women’s dignity throughout pregnancy, labor, delivery, and postpartum. It adapts to each woman’s sociocultural context and beliefs, promoting physical and emotional well-being for mother and newborn while reducing maternal and perinatal morbidity and mortality [3–8].

Humanized childbirth involves practices such as allowing women to have a trusted companion, avoiding unnecessary interventions, ensuring participation in decision-making, and fostering a calm and respectful environment. This care reduces stress and anxiety, shortens recovery and hospital stays, and facilitates better outcomes, including stronger maternal–child bonding and early breastfeeding through immediate skin-to-skin contact [9]. Similarly, respectful maternal care emphasizes human rights protection, emotional support, and the elimination of coercive practices, underscoring the importance of dignity in maternal health care [9]. Both humanized childbirth and respectful maternal care are essential strategies for maternal health, focusing on the care of women but with different priorities.

In recent years, global efforts to promote respectful and high-quality maternal care have gained momentum. The World Health Organization (WHO) declared in 2014 that all women have the right to dignified care during childbirth, free from violence and discrimination [2]. However, progress has been uneven. In Latin America, few countries have implemented data collection systems or enacted legislation to support these principles [10]. Colombia has made strides with the passage of Law 2244 in 2022, which guarantees women’s autonomy, dignified treatment, and access to quality health services during pregnancy and childbirth. This legislation aims to uphold women’s rights and improve maternal care [11].

Despite these advances, adherence to WHO recommendations for humanized care remains low in Latin America [8,12–16]. In Colombia, most studies on humanized childbirth are qualitative and focus on women’s perceptions of maternity care in specific cities [17,18]; evidence suggests slow implementation of WHO guidelines [19], and there are no quantitative studies on the prevalence of humanized childbirth or the factors influencing its practice. This gap limits the ability to assess guideline adherence, inform health policies, and evaluate the impact of Colombia’s Humanized Birth Law.

To address this, the present study aims to estimate the prevalence of humanized childbirth and identify associated factors from the perspective of women in Colombia’s six main cities: Bogotá, Medellín, Cali, Bucaramanga, Manizales, and Pasto. This research will provide critical evidence to guide decision-making, promote the humanization of care, and evaluate the success of policies such as Law 2244.

Materials and methods

Results

A total of 1294 women who gave birth vaginally were interviewed in 2018 in the six cities that made up the sample. We found that 75.4% were living with a partner at the time of childbirth, 81.6% had a secondary education or higher, 68% belonged to a low socioeconomic level, and 63% lived in rented housing. Regarding the characteristics of the pregnancy, 52.4% of the women did not plan their pregnancy; 32.9% had some health problem during pregnancy; 47.3% of the women had a pregnancy classified as risky; 68.1% had a duration of labor of less than 11 hours; 26.2% of the women did not know if the professional attending the childbirth was a general practitioner, and 20% of them did not know if the professional attending the childbirth was a specialist in gynecology and obstetrics (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Prevalence of humanized delivery according to sociodemographic and gestational characteristics.

https://doi.org/10.1371/journal.pone.0326766.t001

The prevalence of humanized childbirth in the sample was 32.9% (95% CI 30.4–35.5). Table 1 displays the prevalence rates for each variable studied, highlighting that the occurrence of humanized childbirth was more frequent among women residing in the city of Cali (43.8%) and those with a higher socioeconomic status (42.8%); women who delivered in their own homes (37. 4%); women whose deliveries were not attended by a gynecologist (41.4%); women whose deliveries were attended by a general practitioner (40.2%); women who attended an antenatal course (39.7%); and women who planned their pregnancies (36.4%).

Table 2 shows the crude and adjusted PRs for the variables considered at each level in the hierarchical conceptual model, with their respective 95% confidence intervals. Among the factors associated with childbirth, the following variables showed an association with childbirth in the crude analysis: place of residence, own home, planned pregnancy, health problems during pregnancy, attendance at an antenatal course, type of facility, sex of the professional attending the childbirth, and whether the childbirth was attended by a general practitioner or a gynecologist. When multicollinearity was assessed using Spearman’s correlation matrix, values higher than 0.45 were not found.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Crude and adjusted associations to humanized childbirths, Colombia, 2018 (n = 1294).

https://doi.org/10.1371/journal.pone.0326766.t002

After multivariate analysis, the following variables were associated with humanized childbirth: city of residence, health problems during pregnancy, attendance at antenatal classes, not knowing whether the childbirth was attended by a gynecologist, and the sex of the professional attending the childbirth. The results of the goodness-of-fit tests of the final multivariate model were adequate. The deviance, chi-square, and the model specification tests showed values of p > 0.05.

Discussion

This study found that the prevalence of humanized childbirth in six capital cities of Colombia was 32.9% (95% CI 30.4–35.5). This means that only one in three women experienced humanized care during pregnancy, labor and delivery, fulfilling the attributes of humanized care, as outlined in current recommendations [2,3] and Law 2244 of 2022 [11]. The prevalence reported here was lower than those reported in other studies, such as Bante et al. in Ethiopia (38.4%; 95% CI 33.7–42.0) [32], a study contucted in Kenya (64%) [33], another study in Ethiopia (56.3%) [34], a study by Tarekenge (65.8%) [35], a study in Costa Rica (50.5%) [36], and a study in Peru (35%) [37].

Conversely, the prevalence of humanized childbirth in this study was higher than that reported by Pereira et al. (19.2%) [38], a study in Mexico (8.4%) [14], and a study in Chile (20.7%) [39]. In these studies, more offensive treatment was reported in public facilities than in private ones, and the incidence of offensive treatment was higher among younger pregnant women (aged 18–29 years), indigenous women, and those with non-heterosexual sexual orientation. These differences may be attributed to the instrument used and the method by which the prevalence of humanized childbirth was estimated in our study. Specifically, this study used a synthetic index that comprehensively captures the multiple human, technical, and procedural dimensions throughout the continuum of maternal care.

The factors associated with humanized childbirth were as follows: the city of residence of the pregnant woman, the presence of health problems during pregnancy, attendance at antenatal course, the sex of the attending professional, and whether the attending professional was a specialist in gynecology and obstetrics. The differences between cities may be explained by variations in how women interact with the health care team, the health care delivery model, and the quality of maternal services in each city, as well as differences in performance of local health system governance in each city [40]. Further studies are needed to clarify these associations.

The association between humanized care and the absence of health problems during pregnancy probably is explained by the fact that complications often require more urgent interventions, which can limit the support available to women, increase stress among healthcare personnel, and make it more difficult to adhere to humanized care protocols. Women who experience complications may also have higher expectations regarding the quality of care due to their greater awareness of potential risks. A study in Malawi found that women without complications during pregnancy reported the highest rates of humanized childbirth [41].

Attendance at antenatal classes was identified as a protective factor for humanized care. These classes facilitate early connections to humanized care, improving interactions between healthcare providers and women. According to the Ministry of Health and Social Protection of Colombia, antenatal classes help develop essential skills for pregnancy, childbirth, and postpartum care [42]. Evidence shows that antenatal education improves pain control, reduces stress, increases vaginal deliveries, and promotes breastfeeding self-efficacy [43,44].

Other finding was that women attended by female healthcare providers were less likely to experience humanized childbirth. Previous studies in Malawi [41] and Ethiopia [32] showed that deliveries attended by male providers were associated with higher scores for respectful humanized care. A possible explanation is that women may have different expectations of care based on the gender of the provider, often expecting more support from female providers or perceiving male providers as more capable. Studies also suggest that female healthcare workers face gender-based discrimination and inequalities, which could influence their perceived quality of care [45,46]. Further research is needed to explore the role of gender and women’s perceptions of maternal care in Colombia.

Finally, the fact that humanized childbirth was lower among mothers who did not know if the attending professional was a specialist in gynecology and obstetrics indicates that there are aspects to be improved in the communication and interaction between health professionals and the mother. This finding can be explained by the conditions at the time of childbirth, which can create feelings of tension and anxiety among the health professionals and in the women, causing them to overlook this aspect.

This study has several strengths. First, it is one of the first quantitative studies conducted in Colombia on this topic, enabling the estimation of prevalence and associated factors in six capital cities. Second, the use of population-based probability sampling allowed for the selection of a sample size sufficient to identify differences between cities and guarantee the precision of the estimates. Another notable strength is the development, validation, and use of an instrument that included all stages of maternity care, from antenatal care to the puerperium. Lastly, the rigor of the statistical methods used strengthens the internal validity of the study.

However, there are several limitations to consider when generalizing the findings. First, as with any cross-sectional study, it cannot establish a cause–effect relationship. Second, the study only included pregnant women from urban areas, particularly capital cities, which may lead to differences in the quality of care compared to women living in small towns or rural areas. Third, potential selection bias should be considered. To evaluate this, we compared certain sociodemographic and healthcare variables, such as maternal age, maternal education, affiliation to the social security health system, number of children, marital status, and attendance at antenatal checkups, among all vaginal births in urban areas in 2018 of women residing in the six selected cities with the characteristics of the sample based on vital statistics data from DANE. No absolute differences of proportions >13% were found, which could be considered clinically relevant. This provides evidence of the representativeness of the study sample and argues against the presence of selection bias. Similarly, only women who had vaginal live births were included in the analysis of humanized care results. This limitation is significant because the cesarean delivery rate in Colombia reached 46.4% in 2015 and 44.6% in 2020 [47], which means that the results apply only to pregnant women who had vaginal births in urban areas.

Given the complexity of measuring humanized care because of its multidimensional nature, and the absence of a reference standard instrument, it was necessary to develop and validate a tool. This instrument would benefit from comparisons with other questionnaires and evaluations in different settings to estimate its concurrent or discriminant validity.

In this context, and analyzing the data from the present study, we assessed the relationship between the humanized childbirth variable and a question from the questionnaire that broadly estimated satisfaction with the care provided during childbirth: “Would you recommend this facility?” The analysis yielded a PR of 18.3 (95% CI 8.2–40.8), adjusted for all variables in the final model (Table 2). This indicates that women who would recommend the facility were 18.3 times more likely to have experienced humanized childbirth compared to women who would not recommend the facility. This result supports the concurrent validity of the humanized birth measure used in the study.

Additionally, owing to mobility restrictions caused by the COVID-19 pandemic, interviews were conducted by phone. While this can be seen as a strength because it facilitated communication, it may also be a limitation if the selected women did not have access to efficient communication devices or lived in areas with limited access. Another limitation was the inability to obtain reliable information on the income of the pregnant women, as many experienced changes in their income due to the pandemic. Furthermore, the COVID-19 pandemic increased the time between childbirth and the interview, which may have led to recall bias. However, studies have shown that women generally remember their maternity care experiences over time [48,49]. We hope that these limitations did not introduce significant bias. In any case, it would be a nondifferential bias, which would not invalidate the results of the study. Moreover, the fact that the study participants were women with live vaginal births from urban areas may limit the generalizability of the findings.

Conclusion

The prevalence of humanized childbirth in the sample of participating cities was 32.9% (95% CI 30.4–35.5). The factors associated with humanized childbirth included the place of residence of the pregnant woman, the presence of health problems during the pregnancy, attendance at the antenatal course, the sex of the attending professional, and whether the attending professional was a gynecologist–obstetrician. These findings provide important evidence for decision-makers to adjust maternal and perinatal care at each stage. It is recommended to monitor the compliance and implementation of current legislation. The validated instrument proposed here can be used for future research to ensure that health services become spaces that promote humanized care.

Supporting information

Acknowledgments

We thank the Secretaries of Health of each of the territorial entities that provided the databases, the participants, the surveyors, the researchers who participated throughout the project, the group of experts who participated in the validation of the instrument, the participating universities, and the Vice-Rectory of Research of Universidad El Bosque.