Maternal and Child Health Journal

, Volume 19, Issue 10, pp 2243–2250 | Cite as

Association Between Disrespect and Abuse During Childbirth and Women’s Confidence in Health Facilities in Tanzania

  • Stephanie Kujawski
  • Godfrey Mbaruku
  • Lynn P. Freedman
  • Kate Ramsey
  • Wema Moyo
  • Margaret E. Kruk



In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite efforts to reduce barriers to utilization. Disrespect and abuse during childbirth has not been explored as a contributor to delivery satisfaction or as a deterrent to institutional delivery. We assessed the association between reported disrespectful treatment during childbirth and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future.


Interviews using a structured questionnaire were conducted in Tanga Region, Tanzania with women on discharge from delivery at two hospitals. Disrespect and abuse was measured by asking women about specific disrespectful events during childbirth. Multivariable logistic regression models were used to assess the association between disrespect/abuse and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders.


1388 women participated in the survey (67 % response rate). Disrespect/abuse during childbirth was associated with lower satisfaction with delivery (OR 0.26, 95 % CI 0.19–0.36) and reduced likelihood of rating perceived quality of care as excellent/very good (OR 0.55, 95 % CI 0.35–0.85). Of women who planned to have more children (N = 766), those who experienced disrespect/abuse were half as likely to plan to deliver again at the same facility (OR 0.51, 95 % CI 0.32–0.82).


Our study highlights disrespectful and abusive treatment during childbirth as an important factor in reducing women’s confidence in health facilities. Improving interpersonal care must be an integral part of quality improvement in maternal health.


Maternal health Disrespect Abuse Quality of care Satisfaction Respectful maternity care 



The authors wish to thank Mr. Jeje Williams for his assistance with data management and Dr. Susie Hoffman for her review of manuscript drafts. We are grateful to the regional and district health authorities and health facility managers in Tanga Region, Tanzania and to the women who generously shared their time and insights in this research. This study was made possible by the support of the Denmark Ministry of Foreign Affairs and the American people through the United States Agency for International Development (USAID) and its Translating Research into Action (TRAction) Project. TRAction is managed by the University Research Co., LLC (URC) under Cooperative Agreement Number GHS-A-00-09-00015-00. The findings of this study are the sole responsibility of the authors, and do not necessarily reflect the views of the Government of Denmark, USAID, or the United States Government. The study sponsors had no role in the collection, analysis, or interpretation of data; in the writing of the paper; or in the decision to submit for publication.

Conflict of interest

The authors declare no competing interests.


  1. 1.
    The World Health Organization. (2014) Trends in maternal mortality: 1990–2013. Geneva.Google Scholar
  2. 2.
    Freedman, L. P., Graham, W. J., Brazier, E., Smith, J. M., Ensor, T., Fauveau, V., et al. (2007). Practical lessons from global safe motherhood initiatives: Time for a new focus on implementation. Lancet, 370(9595), 1383–1391.CrossRefPubMedGoogle Scholar
  3. 3.
    Campbell, O. M. R., & Graham, W. J. (2006). Strategies for reducing maternal mortality: Getting on with what works. Lancet, 368(9543), 1284–1299.CrossRefPubMedGoogle Scholar
  4. 4.
    Say, L., & Raine, R. (2007). A systematic review of inequalities in the use of maternal health care in developing countries: Examining the scale of the problem and the importance of context. Bulletin of the World Health Organization, 85(10), 812–819.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Quijada, C., & Comfort, A. (2002). Maternal Health Financing Profile: Tanzania. Bethesda (MD): Abt Associates Inc.Google Scholar
  6. 6.
    Tanzania National Bureau of Statistics (NBS). (2011) ICF Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro.Google Scholar
  7. 7.
    Avortri, G. D., Beke, A., & Abekah-Nkrumah, G. (2011). Predictors of satisfaction with child birth services in public hospitals in Ghana. International Journal of Health Care Quality Assurance, 24(3), 223–237.CrossRefPubMedGoogle Scholar
  8. 8.
    Wild, K., Barclay, L., Kelly, P., & Martins, N. (2010). Birth choices in Timor-Leste: A framework for understanding the use of maternal health services in low resource settings. Social Science and Medicine, 71(11), 2038–2045.CrossRefPubMedGoogle Scholar
  9. 9.
    Lule, G., Tugumisirize, J., & Ndekha, M. (2000). Quality of care and its effects on utilisation of maternity services at health centre level. East African Medical Journal, 77(5), 250–255.PubMedGoogle Scholar
  10. 10.
    Audo, M., Ferguson, A., & Njoroge, P. (2005). Quality of health care and its effects in the utilisation of maternal and child health services in Kenya. East African Medical Journal, 82(11), 547–553.PubMedGoogle Scholar
  11. 11.
    Tayelgn, A., Zegeye, D. T., & Kebede, Y. (2011). Mothers’ satisfaction with referral hospital delivery service in Amhara Region, Ethiopia. BMC Pregnancy Childbirth, 11(1), 78.PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Sofaer, S., & Firminger, K. (2005). Patient perceptions of the quality of health services. Annual Review of Public Health, 26(35), 513–559.CrossRefPubMedGoogle Scholar
  13. 13.
    Shafiei, T., Small, R., & McLachlan, H. (2012). Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia. Midwifery, 28(2), 198–203.CrossRefPubMedGoogle Scholar
  14. 14.
    Bazant, E. S., & Koenig, M. A. (2009). Women’s satisfaction with delivery care in Nairobi’s informal settlements. International Journal for Quality in Health Care, 21(2), 79–86.CrossRefPubMedGoogle Scholar
  15. 15.
    Hulton, L. A., Matthews, Z., & Stones, R. W. (2007). Applying a framework for assessing the quality of maternal health services in urban India. Social Science and Medicine, 64(10), 2083–2095.CrossRefPubMedGoogle Scholar
  16. 16.
    Larson, E., Hermosilla, S., Kimweri, A., Mbaruku, G. M., & Kruk, M. E. (2014). Determinants of perceived quality of obstetric care in rural Tanzania: A cross-sectional study. BMC Health Services Research, 14, 483.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Andaleeb, S. S. (2001). Service quality perceptions and patient satisfaction: A study of hospitals in a developing country. Social Science and Medicine, 52(9), 1359–1370.CrossRefPubMedGoogle Scholar
  18. 18.
    Atkinson, S., & Haran, D. (2005). Individual and district scale determinants of users’ satisfaction with primary health care in developing countries. Social Science and Medicine, 60(3), 501–513.CrossRefPubMedGoogle Scholar
  19. 19.
    Nabbuye-Sekandi, J., Makumbi, F. E., Kasangaki, A., Kizza, I. B., Tugumisirize, J., Nshimye, E., et al. (2011). Patient satisfaction with services in outpatient clinics at Mulago hospital, Uganda. International Journal for Quality in Health Care, 23(5), 516–523.CrossRefPubMedGoogle Scholar
  20. 20.
    Aldana, J., Piechulek, H., & Al-Sabir, A. (2001). lient satisfaction and quality of health care in rural Bangladesh. Bulletin of the World Health Organization, 79(6), 512–517.Google Scholar
  21. 21.
    Kruk, M. E., Paczkowski, M., Mbaruku, G., de Pinho, H., & Galea, S. (2009). Women’s preferences for place of delivery in rural Tanzania: A population-based discrete choice experiment. American Journal of Public Health, 99(9), 1666–1672.PubMedCentralCrossRefPubMedGoogle Scholar
  22. 22.
    Otis, K. E., & Brett, J. A. (2008). Barriers to hospital births: Why do many Bolivian women give birth at home? Revista Panamericana de Salud Pública, 24(1), 46–53.CrossRefGoogle Scholar
  23. 23.
    Mrisho, M., Schellenberg, J. A., Mushi, A. K., Obrist, B., Mshinda, H., Tanner, M., et al. (2007). Factors affecting home delivery in rural Tanzania. Tropical Medicine and International Health, 12(7), 862–872.CrossRefPubMedGoogle Scholar
  24. 24.
    Kruk, M. E., Mbaruku, G., McCord, C. W., Moran, M., Rockers, P. C., & Galea, S. (2009). Bypassing primary care facilities for childbirth: A population-based study in rural Tanzania. Health Policy Planning., 24(4), 279–288.CrossRefPubMedGoogle Scholar
  25. 25.
    Kruk, M. E., Hermosilla, S., Larson, E., & Mbaruku, G. M. (2014). Bypassing primary care clinics for childbirth: A cross-sectional study in the Pwani region, United Republic of Tanzania. Bulletin of the World Health Organization, 92(4), 246–253.PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Burroughs, T. E., Davies, A. R., Cira, J. C., & Dunagan, W. C. (1999). Understanding patient willingness to recommend and return: A strategy for prioritizing improvement opportunities. Joint Commission Journal on Quality Improvement, 25(6), 271–287.PubMedGoogle Scholar
  27. 27.
    Otani, K., & Waterman, B. (2010). How patient reactions to hospital care attributes affect the evaluation of overall quality of care, willingness to recommend, and willingness to return. Journal of Healthcare Management, 55(1), 25–37.PubMedGoogle Scholar
  28. 28.
    Bowser D, Hill K. (2010). Exploring evidence for disrespect and abuse in facility-based childbirth. Report of a landscape analysis. Washington, DC: USAID.Google Scholar
  29. 29.
    Human Rights Watch. (2011). Stop making excuses: Accountability for maternal health care in South Africa. New York.Google Scholar
  30. 30.
    Radoff, K. A., Levi, A., & Thompson, L. M. (2012). From home to hospital: Mistreatment of childbearing women and barriers to facility-based birth in nicaragua. International Journal of Childbirth, 2(1), 40–50.CrossRefGoogle Scholar
  31. 31.
    Jewkes, R., Abrahams, N., & Mvo, Z. (1998). Why do nurses abuse patients? Reflections from South African obstetric services. Social Science and Medicine, 47(11), 1781–1795.CrossRefPubMedGoogle Scholar
  32. 32.
    D’Ambruoso, L., Abbey, M., Hussein, J. (2005). Please understand when I cry out in pain: Women’s accounts of maternity services during labour and delivery in Ghana. BMC Public Health 5(140).Google Scholar
  33. 33.
    Mselle, L. T., Moland, K. M., Mvungi, A., Evjen-Olsen, B., & Kohi, T. W. (2013). Why give birth in health facility? Users’ and providers’ accounts of poor quality of birth care in Tanzania. BMC Health Services Research, 13, 174.PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Kruk, M. E., Kujawski, S., Mbaruku, G., Ramsey, K., Moyo, W., & Freedman, L. P. (2014). Disrespectful and abusive treatment during facility delivery in Tanzania: A facility and community survey. Health Policy Planning. doi: 10.1093/heapol/czu079.PubMedGoogle Scholar
  35. 35.
    Filmer, D., & Pritchett, L. (2001). Estimating wealth effects without expenditure data–or tears: An application to educational enrollments in states of India. Demography, 38(1), 115–132.PubMedGoogle Scholar
  36. 36.
    Gilson, L. (2003). Trust and the development of health care as a social institution. Social Science and Medicine, 56(7), 1453–1468.CrossRefPubMedGoogle Scholar
  37. 37.
    Russell, S. (2005). Treatment-seeking behaviour in urban Sri Lanka: Trusting the state, trusting private providers. Social Science and Medicine, 61(7), 1396–1407.CrossRefPubMedGoogle Scholar
  38. 38.
    Senarath, U., Fernando, D. N., & Rodrigo, I. (2006). Factors determining client satisfaction with hospital-based perinatal care in Sri Lanka. Tropical Medicine and International Health, 11(9), 1442–1451.CrossRefPubMedGoogle Scholar
  39. 39.
    Hall, J. A., & Dornan, M. C. (1990). Patient sociodemographic characteristics as predictors of satisfaction with medical care: A meta-analysis. Social Science and Medicine, 30(7), 811–818.CrossRefPubMedGoogle Scholar
  40. 40.
    Tateke, T., Woldie, M., & Ololo, S. (2012). Determinants of patient satisfaction with outpatient health services at public and private hospitals in Addis Ababa, Ethiopia. African Primary Health Care and Family Medicine, 4(1), 1–11.Google Scholar
  41. 41.
    Rahmqvist, M., & Bara, A. (2010). Patient characteristics and quality dimensions related to patient satisfaction. International Journal for Quality in Health Care, 22(2), 86–92.CrossRefPubMedGoogle Scholar
  42. 42.
    Al-Mandhari, A. S., Hassan, A. A., & Haran, D. (2004). Association between perceived health status and satisfaction with quality of care: Evidence from users of primary health care in Oman. Family Practice, 21(5), 519–527.CrossRefPubMedGoogle Scholar
  43. 43.
    Gabrysch, S., & Campbell, O. M. R. (2009). Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy Childbirth., 9, 34.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Stephanie Kujawski
    • 1
    • 2
  • Godfrey Mbaruku
    • 3
  • Lynn P. Freedman
    • 2
  • Kate Ramsey
    • 2
  • Wema Moyo
    • 3
  • Margaret E. Kruk
    • 4
  1. 1.Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkUSA
  2. 2.Averting Maternal Death and Disability ProgramColumbia University Mailman School of Public HealthNew YorkUSA
  3. 3.Ifakara Health InstituteDar es SalaamTanzania
  4. 4.Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonUSA

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