There is a clear body of evidence to suggest that a significant number of women globally experience poor levels of care and mistreatment during childbirth.1 Mistreatment is defined as including the concepts of disservice and oppression. Obstetric intervention is now commonplace during childbirth but can be an important factor in predicting a woman's experience and impact on psychological wellbeing.2 For example, seminal work undertaken in 19903 identified that women who felt disempowered during the birthing process exhibited more psychological stress post-birth, and this has been further echoed more recently by other researchers.4,5 Disempowerment also appears to be more evident in hospital-based births, where women feel less in control of their birthing experience, and where there are differing lead professionals providing care.
Recently, in an attempt to address the conceptual confusion surrounding the breadth of terminology and experiences associated with the overarching phenomenon of mistreatment, researchers1 have undertaken a systematic review and development of a typology for the term “mistreatment” of women during childbirth. Within this comprehensive systematic review, mistreatment includes such terms as “obstetric violence”, “dehumanized care” and “disrespect and abuse”. The authors also included deliberate or intentional acts of abuse alongside wider organizational issues, for example a lack of facilities which may compromise the privacy and dignity of women during childbirth.
However, while providing an important contribution to the discourse in this field, the explicit focus on childbirth – which is just one facet of childbearing – arguably does not articulate the potential harms, poor practice or abuse that may occur during the wider period known as childbearing, such as invasive physical examinations and the lack of autonomous choices for women during their pregnancy, lack of understanding around cultural norms, and exclusion or limited delivery preferences. For the purposes of this review, we have adopted the definition of childbearing as “the act or process of carrying and giving birth to a child”.6 (p.295) Childbearing explicitly excludes pre-conceptual and post-natal care.
Using mistreatment and/or obstetric violence as a clearly distinct concept in the broader experience of childbearing, rather than just during the period of childbirth, is worthy of a separate review. A separate systematic review would broaden its application outside of the legal definitions and may start to build an evidence base that illuminates how some obstetric practices, some legally mandated as well as others that are not, are part of a wider culture of gender violence. It also acknowledges the breadth of obstetric care beyond childbirth. This is an important contribution to a growing body of evidence in this field and one that seeks to improve reproductive health and women's rights within the overall childbearing discourse.
While in the United Kingdom (UK) and elsewhere the term “obstetric violence” is not widely utilized, within the Latin American and Caribbean literature obstetric violence (as abusive practice) is well known and has been operationalized through national policy and legislation. For example, a definition taken from Venezuelan Law has been used to contextualize the current literature and the focus for the proposed systematic review as it includes issues relating to a loss of personal autonomy as stated in the following quotation.7 (p.201)
“…[obstetric violence is] the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.”
As such, the term “obstetric violence” offers a distinct contribution in the ongoing awareness raising and investigation into women's experience of assault, violence and abuse by virtue of their pregnancy status at the hands of their care providers and is included within the wider concept of mistreatment. In the instance of the Venezuelan legal definition of “obstetric violence”, a stance is taken as it engenders an underlying assumption that birth should not be pathologized and pregnant women should therefore not be treated per se as if they are “sick”.
A preliminary search was undertaken in the following databases: Embase, AMED, PsycINFO, Web of Science, LILACS GLOBAL HEALTH, MIDIRS (Midwives Information and Resource Service), PASCAL (European science, technology and medicine), ASSIA and SSCI, Cochrane Library and the JBI Database of Systematic Reviews and Implementation Reports. To date, no systematic review addressing this protocol question has been registered and/or completed.
Types of participants
The current review will include women of all ages who have experienced childbearing and who have been in receipt of professional care (those who are recognized as having undergone formal healthcare training for birth practices).
Phenomena of interest
The experiences of mistreatment and/or obstetric violence reported by women during the active period of childbearing (this is defined as the period from conception to birth).
The current review will include any setting globally (hospital and community) where engagement with recognized maternity services and providers of these services have been accessed. Providers may include midwives, birth attendants, doctors, specialist clinicians/practitioners and nurses.
Types of studies
The current review will include studies that include, but are not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. We will include mixed-methods papers only where the qualitative results are reported separately.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe an article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published after 1972 and in English (or where a translation is available) will be considered for inclusion in this review. The date of 1972 has been chosen as this coincides with the publication of the “Peel Report” (1970) which was arguably a significant development in terms of changing the landscape of maternity care and service provision in the UK8 and which subsequently influenced maternity services in other countries.
The databases to be searched include MEDLINE (using Ovid), CINAHL, Embase, AMED, PsycINFO, Web of Science, LILACS GLOBAL HEALTH, MIDIRS (Midwives Information and Resource Service), PASCAL (European science, technology and medicine), ASSIA (Applied Social Sciences Index and Abstracts) and SSCI (Social Sciences Citation Index). The search for unpublished studies will include reports from the World Health Organization, National and international organizations and bodies including the UK Royal College of Nursing and Royal College of Midwifery and examining conference proceedings. Further electronic searching will be utilized using Google Scholar as a reference point. Keywords will be used and include women, abuse (verbal, physical, sexual and psychological), loss of autonomy, refusal of medication, pain, consent, discrimination, discriminatory practice, culture, obstetric violence, mistreatment, pregnancy, birth attendant, nurse, midwife, doctor, medic, professional, childbearing, traumatic birth and experience. MESH headings for each of the databases plus Boolean operators (AND/OR) plus wild cards (women/woman, paediatric/paediatric) will be used. A sample search strategy has been developed (Appendix I).
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using a standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion among the review team.
If eligibility is not clear from the information provided in the paper, all efforts will be made to seek clarification through contact with the original authors.
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix III). The data extracted will include specific details about the phenomena of interest, populations, study methods, contexts and outcomes of significance to the review questions and specific objectives. One reviewer (the primary reviewer) will extract the data and thereafter will discuss with the review team as a form of verification and validation to minimize the possibility of error. As above, we will contact authors of papers if there are any issues that require clarification during data extraction.
Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
The current protocol builds on earlier discussions with colleagues in Sao Paulo, Brazil, during an educational researcher links workshop and was originally funded by the British Council Researcher Links initiative 2014. Funding was received to develop the review protocol from The Nottingham Centre for Evidence-Based Healthcare, Nottingham, UK.