Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings. Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO's multicountry study 'How women are treated during facility-based childbirth' (2016-2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability. Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index and a 12-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries based on factor loadings and interitem correlations, indicating good structural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.60 in Ghana and Guinea. Low correlations (Spearman correlation range: -0.06-0.19; p≥0.05) between mistreatment measures supported our decision to develop three separate measures. Predictive criterion validation yielded mixed results across countries. Both items within measures and measure scores were internally consistent across countries; each item co-occurred with other items in a measure, and scores consistently distinguished between 'high' and 'low' mistreatment levels. The set of concise, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify burden, identify risk factors and determine its impact on health and well-being outcomes. Further validation and reliability testing of the measures in other contexts is needed.

Background

There has been substantial progress in developing approaches to measure mistreatment of women during childbirth. However, less is known about the differences in measurement approaches. In this study, we compare measures of mistreatment obtained from the same women using labour observations and community-based surveys in Ghana, Guinea and Nigeria.

Methods

Experiences of mistreatment during childbirth are person-centred quality measures. As such, we assessed individual-level and population-level accuracy of labour observation relative to women's self-report for different types of mistreatment. We calculated sensitivity, specificity, percent agreement and population-level inflation factor (IF), assessing prevalence of mistreatment in labour observation divided by 'true' prevalence in women's self-report. We report the IF degree of bias as: low (0.75Results1536 women across Ghana (n=779), Guinea (n=425) and Nigeria (n=332) were included. Most mistreatment items demonstrated better specificity than sensitivity: observation of any physical abuse (44% sensitive, 89% specific), any verbal abuse (61% sensitive, 73% specific) and presence of a labour companion (19% sensitive, 93% specific). Items for stigma (IF 0.16), pain relief requested (IF 0.38), companion present (IF 0.32) and lack of easy access to fluids (IF 0.46) showed high risk of bias, meaning labour observations would substantially underestimate true prevalence. Other items showed low or moderate bias.

Conclusion

Using self-report as the reference standard, labour observations demonstrated moderate-to-high specificity (accurately identifying lack of mistreatment) but low-to-moderate sensitivity (accurately identifying presence of mistreatment) among women. For overall prevalence, either women's self-report or observations can be used with low-moderate bias for most mistreatment items. However, given the dynamicity, complexity, and limitations in 'objectivity', some experiences of mistreatment (stigma, pain relief, labour companionship, easy access to fluids) require measurement via women's self-report. More work is needed to understand how subjectivity influences how well a measure represents individual's experiences.