Developing Measures to Assess Mistreatment of Women During Facility-Based Childbirth
Berger, Blair Olivia
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Background: Mistreatment of women during childbirth is increasingly recognized as a significant issue globally. Research and programmatic efforts targeting mistreatment have been limited by a lack of validated measurement tools. This study aimed to develop a set of valid and reliable multidimensional measures for mistreatment. Secondly, it examined individual, provider, and delivery factors associated with mistreatment. Methods: Continuous labor observations of 1,974 women in Nigeria (n=407), Ghana (n=912), and Guinea (n=655) were used from the World Health Organization’s Multi-Country Study on How Women are Treated during Childbirth. Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified OECD approach for generating composite indexes. Measures were evaluated for performance, construct validity, and internal consistency/reliability. Multivariable fixed effects logistic regression was conducted to identify factors associated with higher-than-average scores on each mistreatment measure. Results: Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index, and an 11-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries, indicating good structural and cross-cultural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.6 in Ghana and Guinea. Low correlations between mistreatment measures further supported construct validity of three separate measures. Construct validation via hypothesis testing 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. Results of the multivariate correlates analysis were mixed. Age, education, parity, type of labor and birth attendants, and time of delivery were positively and negatively associated with higher levels of mistreatment in the three settings, underscoring wide variation in risk profiles for mistreatment by context. Conclusions: The set of condensed, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify the burden, identify risk factors, and determine its impact on health outcomes. Further validation and reliability testing of the measures is needed.