| |

Received: 26 April 2017 Revised: 17 August 2017 Accepted: 17 October 2017

DOI: 10.1002/ijgo.12353

CLINICAL ARTICLE
Obstetrics

Disrespect and abuse during childbirth in fourteen hospitals in

nine cities of Peru

Rene Montesinos-Segura1,*|Diego Urrunaga-Pastor2|Giuston Mendoza-Chuctaya1|

Alvaro Taype-Rondan3|Luis M. Helguero-Santin4|Franklin W. Martinez-Ninanqui1|
Dercy L. Centeno5|Yanina Jimnez-Meza6|Ruth C. Taminche-Canayo7|
Liz Paucar-Tito1|Wilfredo Villamonte-Calanche8

1
Escuela Profesional de Medicina Humana,
Universidad Nacional de San Antonio Abad del Abstract
Cusco, Cusco, Peru Objective: To assess the prevalence of disrespect and abuse during childbirth and its
2
Sociedad Cientfica de Estudiantes de
associated factors in Peru.
Medicina de la Universidad de San Martin
de Porres, Facultad de Medicina Humana, Methods: In an observational cross-sectional study, women were surveyed within
Universidad de San Martin de Porres,
48hours of live delivery at 14 hospitals located in nine Peruvian cities between April
Lima, Peru
3 and July 2016. The survey was based on seven categories of disrespect and abuse
CRONICAS Center of Excellence in Chronic
Diseases, Universidad Peruana Cayetano proposed by Bowser and Hill. To evaluate factors associated with each category, prev-
Heredia, Lima, Peru
alence ratios (PRs) and 95% confidence intervals (CIs) were calculated using adjusted
4
Sociedad Cientfica de Estudiantes de
Medicina de la Universidad Nacional de Piura, Poisson models with robust variances.
Facultad de Medicina Humana, Universidad Results: Among 1528 participants, 1488 (97.4%) had experienced at least one cate-
Nacional de Piura, Piura, Peru
5
gory of disrespect and abuse. Frequency of abandonment of care was increased with
Sociedad Cientfica Medico Estudiantil San
Cristobal, Escuela Profesional de Medicina cesarean delivery (PR 1.27, 95% CI 1.031.57) but decreased in the jungle region (PR
Humana, Universidad Nacional de San 0.27, 0.140.53). Discrimination was associated with the jungle region (PR 5.67,
Cristbal de Huamanga, Ayacucho, Peru
6 2.3213.88). Physical abuse was less frequent with cesarean than vaginal delivery
Sociedad Cientfica Mdico Estudiantil
ContinentalFacultad de Medicina Humana, (PR 0.23, 0.110.49). The prevalences of abandonment of care (PR 0.42, 0.290.60),
Universidad Continental, Junn, Peru
non-consented care (PR 0.70, 0.570.85), discrimination (PR 0.40, 0.190.85), and
7
Sociedad Cientfica de estudiantes de
Medicina de la Amazona Peruana,
non-confidential care (PR 0.71, 0.550.93) were decreased among women who had
Escuela Profesional de Medicina Humana, been referred.
Universidad Nacional de la Amazona Peruana,
Iquitos, Peru
Conclusion: Nearly all participants reported having experienced at least one category
8
Centro de Investigacin de Medicina of disrespect and abuse during childbirth care, which was associated with type of
Materno Fetal de Altura, Servicios de Salud delivery, being referred, and geographic region.
CENIMFA SAC, Cusco, Peru

*Correspondence KEYWORDS
Rene Montesinos-Segura, Urb. Marcavalle Disrespect; Human rights abuse; Obstetric delivery; Obstetric labor; Patient advocacy; Patient
A-20, Distrito de Wanchaq, Cusco, Per. rights; Reproductive rights
Email: mrenee.ms@gmail.com

This article includes a Spanish translation

of the Abstract, available in the Supporting
Information section.

Funding Information
Sociedad Cientfica Mdico
Estudiantil Peruana

Int J Gynecol Obstet 2017; 17 2017 International Federation of | 1

wileyonlinelibrary.com/journal/ijgo
Gynecology and Obstetrics
 |
2 Montesinos-Segura ETAL.
1| INTRODUCTION
Disrespect and abuse during childbirth care is considered a form
of violence that directly violates womens rights as defined by the
United Nationsi.e. the right to respect, timely care, autonomy,
self-determination, and information during childbirth.1 Thus, many
countries have issued laws that sanction acts of disrespect and abuse
during childbirth. Additionally, disrespect and abuse could have impor-
tant consequences for women and their care-seeking behaviors, such
as decreased willingness to seek institutionalized delivery,2 decreased
satisfaction with received care,3 reduced confidence in health person-
nel and the health system,4,5 decreased desire to have more vaginal
deliveries,4 and even reduced production of breast milk.6
Several studies have been performed to evaluate disrespect and
abuse during childbirth710; however, they have used different defini-
tions and instruments for evaluation, making it difficult to adequately
compare their findings. Therefore, WHO has emphasized the need not
only to standardize the operational definition of disrespect and abuse,
but also to develop standardized tools for its measurement.1
In 2010, Bowser and Hill elaborated a definition of disrespect
and abuse through a systematic landscape analysis of published and
grey literature, and by conducting individual interviews with expert
informants and holding a structured group discussion on the topic.11
Their definition covers seven categories: (1) non-confidential care, (2)
physical abuse, (3) abandonment of care, (4) detention in facility, (5)
11,12
non-consented care, (6) discrimination, and (7) non-dignified care.
Such an extended definition of disrespect and abuse has rapidly
become widespread and has been used by the Health Policy Project
to create the Respectful Maternity Care guide.12 It has also been used
13 14
in several studies, including one in Kenya, one in Ethiopia, three in
Tanzania,5,15,16 one in Nigeria,17 and a multi-country study in Africa.18
These studies have reported the prevalence of disrespect and abuse in
childbirth to vary between 12.2% and 98%.
Health inequity is a latent subject in Peru, where just over 20years
ago, many women of a low educational level were pressured to undergo
surgical sterilization presumably without adequate information and
even without proper postsurgical care.19 However, recent studies have
reported that, at present, gender discrimination does not seem to rep-
resent an important element of the Peruvian health system.20,21
Despite the importance of disrespect and abuse during childbirth,
few studies have addressed this issue in Latin American countries.
For example, a study in Mexico evaluated only physical abuse and
non-dignified care,10 whereas two studies in Venezuela limited their
evaluation to non-consented care, physical abuse, and non-dignified
care.7,8 A study in Brazil evaluated physical abuse and abandonment of
care.9 In Peru, one study evaluated non-dignified care, abandonment
of care, and non-confidential care,22 whereas another evaluated non-
consented care and non-confidential care for vaginal examination.23 To
our knowledge, no study has evaluated all seven disrespect and abuse
categories proposed by Bowser and Hill in this geographic region.
This lack of information in Latin America makes it difficult to prop-
erly evaluate the occurrence of disrespect and abuse, and to design
and implement public policies for its prevention. Therefore, the aim of
the present study was to address this gap and assess the prevalence of
disrespect and abuse during childbirth and its associated factors in 14
hospitals in nine cities of Peru.
2|MATERIALS AND METHODS
The present observational cross-sectional study was performed
among women who delivered in 14 regional hospitals located in
nine urban Peruvian cities between April 1 and July 31, 2016. The
research project was approved by the Institutional Review Board of
the San Bartolome Hospital (RCEI-40), Lima, Peru. Authorization was
also given by each of the evaluated hospitals. Informed consent was
obtained from participants before the survey, when it was clarified
that participation was voluntary and participants could refrain from
answering any question or leave the study at any time. It was also
clarified that the choice to take a part in the study would not change
the health care delivered by the hospital. Anonymity of the partici-
pants and confidentiality of the data were ensured.
The study hospitals were located in two cities in the coastal
region (Chiclayo and Piura), five in the highlands (Cusco, Huamanga,
Huancayo, Cerro de Pasco, and Puno), and two in the jungle (Iquitos
and Tarapoto) (Fig.1). The original objective was to perform the study
in Peruvian cities with higher numbers of inhabitants, but permission
was granted only in some hospitals in some cities, where the study was
ultimately performed.
The participants were women who were under observation in
the hospitals after delivering a live neonate within the past 48hours.
Women with neurocognitive disorders or who refused to participate in
the study were excluded.
The survey design was based on the categories of disrespect and
abuse during childbirth proposed by Bowser and Hill.11 For each cate-
gory, a list of the items proposed by the guide of Respectful Maternity
Care12 was supplemented with other items proposed by previous
studies that also used these categories,1317 thereby generating a list
of 36 items related to disrespect and abuse during childbirth.
The final list was assessed by 17 Peruvian experts, including gyne-
cologists, obstetricians, and epidemiologists. Additionally, a pilot study
was undertaken in seven cities (3 in coastal regions, 3 in the high-
lands, and 1 in the jungle), surveying 30 women who had had a live
birth in the past 48hours in each city. In both evaluations, experts and
mothers were asked about the clarity of each item and its relevance to
the disrespect and abuse construct. The questions were rephrased to
ensure clarity among the target audience. The Spanish version of the
final survey is presented in Table S1.
A multicenter research group was formed with participants from
nine cities in Peru who received permission to conduct the survey in
14 hospitals: 10 were public hospitals pertaining to the Ministry of
Health (MINSA), and 4 were public hospitals pertaining to the Social
Security Systems (EsSalud). MINSA and EsSalud are the main health-
care systems in Peru, providing healthcare for 37.0% and 21.0% of
Peruvians, respectively.24 EsSalud hospitals tend to have a higher bud-
get and are better equipped than MINSA hospitals. Patients at MINSA
Montesinos-Segura ETAL.
F I G U R E 1 Map of the nine cities in Peru where the study was conducted.
facilities come mostly from rural and marginal urban areas, where the
level of poverty is higher. Comparatively, EsSalud patients are usually
formal workers, retirees, or relatives of workers and retirees.
The surveys were conducted on 37days per week, depending
on the availability of the team. All women who were in the postnatal
wards and met the inclusion criteria were surveyed, and at least 100
surveys were completed in each hospital. The 100-survey threshold
was chosen by consensus among the researchers on the basis of the
feasibility of conducting the surveys at each hospital.
For administration of the survey, the interviewers led the woman
to a private room or, if this was not possible, they verified that the hos-
pitals health personnel were not nearby to avoid bias in the responses
of the participants. To try to avoid changes in the treatment of the
mothers, discretion was used to ensure that most health personnel
did not know that the study was being conducted. In most cases, only
the hospitals institutional review board knew about the study. The
surveys were conducted in Spanish or Quechuan, in accordance with
the womens language preference. Survey responses were typed inde-
pendently by two researchers into Excel 2016 (Microsoft, Redmond,
WA, USA), resulting in two databases that were subsequently com-
pared; data that did not match were reviewed for correction.
A positive answer to at least 1 of the 36 items in the survey was
taken to indicate that the participant had experienced disrespect and
|
3
abuse in childbirth. Furthermore, a positive answer to at least one of
the items corresponding to each category (non-confidential care, dis-
crimination based on patients attributes, non-consented care, non-
dignified care, abandonment of care, detention in facility, and physical
abuse) was taken to indicate that the participant had experienced that
category of disrespect and abuse during childbirth. The number of cat-
egories experienced concurrently by the participants was also deter-
mined by evaluating how many categories had a positive response.
The following sociodemographic variables were collected: age in
years, level of education, and area of residence (urban or rural). The
number of previous deliveries (0 or 1) and number of prenatal care
visits (dichotomized as <6 or 6 visits as per the cutoff point proposed
by MINSA25) were also recorded, along with whether the participant
was referred from another health facility for the current delivery (yes
or no), type of delivery (vaginal or cesarean), and dependence of the
health facility (MINSA or EsSalud). Hospitals were categorized by their
geographic region as coastal, highlands, or jungle. The rationale for this
division was the differences in hospital infrastructure and healthcare
practices observed among these geographic regions.
Data analysis was performed using STATA version 14.0 (StataCorp,
College Station, TX, USA). The study data were described as absolute
frequencies, relative frequencies, and meanSD. To explore the fac-
tors associated with each category of disrespect and abuse, prevalence
 |
4 Montesinos-Segura ETAL.

ratios and 95% confidence intervals were calculated by using adjusted T A B L E 2 Sociodemographic characteristics of the study
Poisson regression with robust variance; sandwich estimators were population (n=1528).a
also used on the assumption that data would be clustered in hospitals.
Characteristic Value
P<0.05 was considered to be statistically significant.
Age, y 26.66.3
1323 525 (34.4)
2429 520 (34.0)
3| RESULTS
3045 483 (31.6)

In total, 1538 postpartum women were asked to participate in the Level of education
study, of whom 10 refused. Hence, data were collected from 1528 No formal education/primary only 515 (33.7)
women: 440 (28.8%) in hospitals of the coastal region, 659 (43.1%) in 1y of secondary education 517 (33.8)
the highlands, and 429 (28.1%) in the jungle. The overall prevalence of 1y of higher education 496 (32.5)
having experienced at least one category of disrespect and abuse was Area of residence
1488 (97.4%). The values ranged from 70.0% to 100% across the 14 Urban 1254 (82.1)
hospitals studied (Table1).
Rural 273 (17.9)
The respondents had a meanSD age of 26.66.3years; 937
Previous deliveriesb
(61.4%) of 1526 had at least one previous delivery; and 968 (63.4%) of
0 589 (38.6)
1528 had a vaginal delivery in the index pregnancy (Table2).
1 937 (61.4)
Regarding the different categories, the most prevalent form of disre-
Prenatal care visits
spect and abuse was non-dignified care (86.2% [1296/1504]), followed
by non-consented care (74.6% [1101/1475]), and non-confidential <6 422 (27.6)

care (68.1% [1037/1523]) (Table S2). Figure2 shows the number of 6 1106 (72.4)

concurrent categories of disrespect and abuse reported. The number Type of delivery
of women who experienced two or more categories of disrespect and Vaginal 968 (63.4)
abuse concurrently was 1358 (88.9%), whereas that of women who Cesarean 560 (36.6)
experienced four or more categories concurrently was 850 (55.6%). Referred from another health facility
No 935 (61.2)
T A B L E 1 Characteristics of the hospitals where the study was
performed, by geographic region. Yes 593 (38.8)
Dependence
No. of Prevalence
Ministry of health 1088 (71.2)
surveys of disrespect
Hospital Dependence analyzed and abusea EsSalud 440 (28.8)

Coastal Geographic region

Hospital 1 MINSA 110 109 (99.1) Coast 440 (28.8)

Hospital 2 MINSA 110 110 (100.0) Highlands 659 (43.1)

Hospital 3 EsSalud 110 110 (100.0) Jungle 429 (28.1)

a
Hospital 4 EsSalud 110 110 (100.0) Values are given as meanSD or number (percentage).
b
Data missing for 2 participants.
Highlands
Hospital 5 MINSA 110 110 (100.0)
Hospital 6 MINSA 100 110 (100.0)
Proportion of participants (%)

Hospital 7 MINSA 100 70 (70.0) 30%

Hospital 8 MINSA 129 126 (97.7) 25%
Hospital 9 MINSA 110 110 (100.0)
20%
Hospital 10 EsSalud 110 109 (99.1)
15%
Jungle
10%
Hospital 11 MINSA 110 110 (100.0)
Hospital 12 MINSA 110 110 (100.0) 5%
Hospital 13 MINSA 99 95 (96.0) 0%
0 1 2 3 4 5 6 7
Hospital 14 EsSalud 110 110 (100.0)
No. of concurrent categories
Abbreviations: MINSA, Ministry of Health of Peru; EsSalud, Social Security
System of Peru. F I G U R E 2 Number of concurrent categories of disrespect and
a
Values are given as number (percentage). abuse during childbirth reported by the study women.
Montesinos-Segura ETAL. |
5

Factors associated with experiencing each category of disrespect 4|DISCUSSION

and abuse were assessed by adjusted models, which showed that
women who delivered by cesarean had a higher prevalence of aban-
donment of care and a lower prevalence of physical abuse as com-
pared with women who delivered vaginally (Table3). Women referred
from other health facilities had a lower prevalence of abandonment of
care, non-consented care, discrimination, and non-confidential care as
compared with women who were not referred (Table3). With regard to
geographic region, abandonment of care was significantly more com-
mon in the coastal region than in the jungle, whereas discrimination
was significantly more common in the jungle than at the coast (Table3).
Almost all the postpartum women surveyed in the present study had
experienced at least one of the categories of disrespect and abuse
during childbirth. Non-dignified care was the most common form
of disrespect and abuse, followed by non-consented care, and non-
confidential care. More than half of all participants experienced at
least four categories of disrespect and abuse concurrently. Type of
delivery, referral from other health facilities, and geographic region
were associated with at least one form of disrespect and abuse; how-
ever, the associated factors differed for each category.

T A B L E 3 Adjusted analysis of the factors associated with each category of disrespect and abuse.a

Abandonment of Non-dignified Non-consented Non-confidential

Variable Physical abuse care care care Discrimination care

Age group, y
1323 Ref. Ref. Ref. Ref. Ref. Ref.
2429 1.01 (0.851.19) 0.99 (0.821.20) 1.00 (0.951.05) 1.04 (0.981.11) 0.99 (0.791.24) 1.00 (0.921.08)
3045 1.01 (0.851.21) 0.92 (0.731.17) 0.99 (0.911.08) 0.95 (0.871.05) 1.00 (0.721.37) 0.91 (0.791.05)
Level of education
No formal education/ Ref. Ref. Ref. Ref. Ref. Ref.
primary only
1y of secondary education 0.84 (0.701.02) 1.02 (0.761.38) 1.00 (0.921.08) 0.78 (0.581.04) 0.75 (0.461.24) 0.89 (0.731.10)
1y of higher education 0.88 (0.681.14) 1.37 (0.932.04) 1.08 (0.981.19) 0.83 (0.601.15) 0.94 (0.531.66) 0.89 (0.721.09)
Area of residence
Urban Ref. Ref. Ref. Ref. Ref. Ref.
Rural 1.00 (0.821.22) 1.09 (0.871.38) 1.06 (0.991.13) 0.84 (0.651.09) 1.26 (0.582.74) 0.98 (0.791.22)
Previous deliveries
0 Ref. Ref. Ref. Ref. Ref. Ref.
1 1.00 (0.921.08) 1.08 (0.931.25) 1.02 (0.951.08) 0.99 (0.911.08) 1.05 (0.841.31) 1.00 (0.941.07)
Prenatal care visits
<6 Ref. Ref. Ref Ref. Ref. Ref.
6 0.96 (0.831.10) 1.20 (0.881.65) 1.00 (0.941.07) 0.91 (0.771.08) 0.97 (0.741.28) 0.97 (0.841.13)
Type of delivery
Vaginal Ref. Ref. Ref. Ref. Ref. Ref.
Cesarean 0.23 (0.110.49) 1.27 (1.031.57) 1.11 (0.961.29) 1.02 (0.901.16) 0.84 (0.581.21) 1.11 (0.931.33)
Referred from another
health facility
No Ref. Ref. Ref. Ref. Ref. Ref.
Yes 0.76 (0.581.01) 0.42 (0.290.60) 0.85 (0.691.04) 0.70 (0.570.85) 0.40 (0.190.85) 0.71 (0.550.93)
Dependence
Ministry of health Ref. Ref. Ref. Ref. Ref. Ref.
EsSalud 1.19 (1.031.37) 0.67 (0.401.11) 0.98 (0.901.07) 0.99 (0.781.25) 0.72 (0.361.43) 0.99 (0.861.16)
Geographic region
Coast Ref. Ref. Ref. Ref. Ref. Ref.
Highlands 1.03 (0.781.36) 0.69 (0.391.20) 0.80 (0.660.98) 0.96 (0.801.14) 2.48 (0.817.54) 0.96 (0.761.22)
Jungle 0.79 (0.571.09) 0.27 (0.140.53) 1.06 (0.971.15) 0.78 (0.471.32) 5.67 (2.3213.88) 1.07 (0.781.47)
a
Values are given as prevalence ratio (95% confidence interval) and were calculated using adjusted Poisson regression with robust variance; sandwich
estimators were also used on the assumption that data would be clustered in hospitals. For each category of disrespect and abuse, models were adjusted
for all variables included in the table. The category Detention in facility due to non-payment was not evaluated owing to the low number of outcomes.
 |
6 Montesinos-Segura ETAL.
The present prevalence of disrespect and abuse (97.4%) is similar
17
to the level found in a hospital in Nigeria (98%), but higher than that
found in four hospitals and three health centers in Ethiopia (78.6%).14
It is also higher than the percentage reported in one hospital in
Tanzania (15.0%),16 eight hospitals in Tanzania (18.0%),5 and 13 hospi-
tals in Kenya (20%).13 The previous studies used the same definitions
for the categories of disrespect and abuse as the present study, but
used fewer items: whereas 36 items were used in the present study,
the studies in Nigeria, Tanzania, Ethiopia, and Kenya used 28, 28, 23,
and 10 items, respectively.13,14,16,17
On the basis of the high prevalence of disrespect and abuse identi-
fied in the present study, interventions should be promptly implemented.
One of the main causes of disrespect and abuse is possibly the lack of
information and lack of training for health personnel. Face-to-face and
virtual training might be used to enhance the capability of healthcare
workers, and the importance of education to empower women should
be emphasized. For example, human resource centers for women to
make complaints of disrespect and abuse safely and comfortably might
be implemented. The efficacy of these interventions might be gauged
by measuring the prevalence of disrespect and abuse at various time
intervals.
Other important features in the present context are the deficiencies
in the infrastructure for childbirth care, such as a lack of room availabil-
ity, blinds, and health personnel, and dissatisfaction among health per-
sonnel.25 These aspects require further study in addition to intervention.
Non-dignified care was the most prevalent category in the pres-
ent study, which is similar to the findings of a study in Kenya,13 but
different from studies in Nigeria17 and Tanzania.16 In the two latter
countries, the most prevalent categories were non-consented care17
16
and abandonment of care, respectively. Such differences indicate
that disrespect and abuse during childbirth is dependent on context,
meaning that approaches specific to each setting are required.
The prevalence of disrespect and abuse was found to differ across
hospitals. Furthermore, individual categories such as discrimination
and abandonment of care were different across geographic regions.
This suggests that these problems should not be uniformly addressed
throughout the country, and that each hospital and geographic region
should prioritize interventions according to their particular context.
The present study also found a high prevalence of women expe-
riencing more than one category of disrespect and abuse. This aspect
has not been evaluated in previous studies. Experiencing more than
one category might have increased consequences for women in terms
of dissatisfaction with the healthcare system, decreased use of institu-
tional delivery, and depression. Future studies should assess the prev-
alence and consequences of multiple abuses.
The prevalence of discrimination was lower in the coastal region
(9.1%), higher in the highlands (25.8%), and highest in the jungle
(75.8%). These statistics might reflect a greater vulnerability of the
Peruvian population in the highlands and jungle, differences in the
perception of discrimination among regions, or differences in training
of the health personnel among these geographic regions.
Abandonment of care was more common in the coastal region than
in the highlands or the jungle. Within this category, a refused request
to have a companion present during delivery was most prevalent. This
might be attributed to the smaller and more overcrowded labor rooms
in hospitals in the coastal region as compared with the highlands or
jungle, which makes it difficult to allow the presence of a birth com-
panion. Such a restriction violates the protocol of care established by
the Ministry of Health of Peru, which promotes the participation of a
companion chosen by the pregnant woman throughout their labor.25
Cesarean delivery was found to be a protective factor against
physical abuse, possibly because women who deliver by cesarean
undergo fewer procedures relative to those who have vaginal deliv-
ery involving, for example, Kristeller maneuver or episiotomy without
anesthesia. However, it was also associated with abandonment of
care, possibly due to the complexity of having a companion during
pre-cesarean preparation.
Referral from other health centers was also considered to be a pro-
tective factor in several categories of disrespect and abuse. This might
be because referred women arrive during an advanced stage of labor
and spend less time in the hospital. Moreover, they are often referred
because they present risk factors or obstetric complications, meaning
that they receive more attention and accompaniment.
The present study has some limitations. First, the aim was to gener-
ate a validated survey of disrespect and abuse suitable for all Peruvian
hospitals; however, each geographic region has its own unique cultural
features and traditions. As a result, it is possible that some of the items
listed in the survey were not part of the disrespect and abuse con-
struct in some contexts. Moreover, although the present study aimed
to use the same categories of disrespect and abuse as other stud-
ies,5,1315,17,18 the number of items varied in previous investigations.
Second, the length of the survey was a limiting factor, as also reported
in other studies.16,17 Third, the participants might have felt intimidated
by the hospital environment, which in turn might have influenced their
responses; however, the interviewers emphasized the anonymity of
the survey and, in an attempt to reduce this bias, conducted the sur-
vey when no health personnel were in the room. Fourth, only women
who had delivered in the past 48hours were surveyed; this population
of women could have been affected by immediate distressing factors
related to labor, which might have influenced their answers; however,
this limitation is shared by previous studies.1416
The study also has strengths. To our knowledge, it is the first to
evaluate the seven categories of disrespect and abuse during child-
birth in health facilities in a Latin American country, and one of the
few studies to have been performed in several hospitals and more
than one city. As a result, it provides much information for the devel-
opment of public policies to tackle disrespect and abuse in Peru and
other countries.
In conclusion, the present investigation found that almost all
women surveyed had experienced at least one category of disrespect
and abuse during childbirth care. There were differences in the over-
all prevalence across hospitals and geographic regions. The follow-
ing factors were associated with at least one category of disrespect
and abuse: type of delivery (i.e. vaginal or cesarean), referral from
another health facility, dependence of the health facility, and geo-
graphic region. The findings indicate that interventions to reduce the
Montesinos-Segura ETAL.
prevalence of disrespect and abuse should be promptly implemented,
considering the use of different approaches in each region.
AUT HOR CONTRI B UTI O N S
RM-S, AT-R, and WV-C designed the study. RM-S and AT-R trained the
interviewers for data collection. RM-S, LMH-S, FWM-N, DLC, LP-T, YJ-
M, and RCT-C collected the data. RM-S, DU-P, GM-C, LMH-S, and AT-R
performed the statistical analyses. All authors participated in data inter-
pretation and manuscript preparation, and all approved its final version.
ACKNOWLE DG ME NTS
Sheyla Yucra-Soto assisted with the design of the study. Laura R.
Arce-Villalobos, Elvia Vicente-Guerra, Pamela D. Flores-Gonzales, and
Liussmyth S. Vega assisted with data collection and typing the sur-
vey results. Safia S. Jiwani, Jessica Zafra-Tanaka, Maria Lazo-Porras
and J. Jaime Miranda critically reviewed the manuscript. The present
research was partly funded by Sociedad Cientfica Mdico Estudiantil
Peruana. Other outgoings were self-financed by the authors.
CO NFLI CTS OF I NTE RE S T
The authors have no conflicts of interest.
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S U P P O RT I NG I NFO R M AT I O N
Additional Supporting Information may be found online in the support-
ing information tab for this article.
Table S1. The study survey in Spanish.
Table S2. Prevalence of items in each category of disrespect and abuse
in childbirth.
File S1. Spanish translation of abstract.