Abstract

Introduction

Disrespect and abuse during childbirth - also known by the terms of maltreatment of women during childbirth, obstetric violence, institutional gender violence during childbirth, and inhumane/dehumanized care - is a result of the conditions and restrictions of health systems and, more often, of the interaction between health professionals and women ¹1. Diniz SG, Salgado HO, Andrezzo HFA, Carvalho PGC, Carvalho PCAC, Aguiar CA, et al. Violência obstétrica como questão para a saúde pública no Brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção. J Hum Growth Dev 2015; 25:377-84-8.^,22. Tesser CD. Violência obstétrica e prevenção quaternária: o que é e o que fazer. Rev Bras Med Fam Comunidade 2015; 10:1-12.^,33. Sadler M, Santos MJ, Ruiz-Berdún D, Rojas GL, Skoko E, Gillen P, et al. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reprod Health Matters 2016; 24:47-55.^,44. Leite TH, Marques ES, Esteves-Pereira AP, Nucci MF, Portella Y, Leal MC. Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil. Ciênc Saúde Colet 2022; 27:483-91.. There is no consensus on the terminology used ⁴4. Leite TH, Marques ES, Esteves-Pereira AP, Nucci MF, Portella Y, Leal MC. Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil. Ciênc Saúde Colet 2022; 27:483-91. and, therefore, this article will use the term disrespect and abuse due to its frequent use in the international literature ³3. Sadler M, Santos MJ, Ruiz-Berdún D, Rojas GL, Skoko E, Gillen P, et al. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reprod Health Matters 2016; 24:47-55.^,55. Tobasía-Hege C, Pinart M, Madeira S, Guedes A, Reveiz L, Valdez-Santiago R, et al. Irrespeto y maltrato durante o parto e o aborto na América Latina: revisão sistemática y metaanálisis. Rev Panam Salud Pública 2019; 43:e36.^,66. Mesenburg MA, Victora CG, Jacob Serruya S, Ponce de León R, Damaso AH, Domingues MR, et al. Disrespect and abuse of women during the process of childbirth in the 2015 Pelotas birth cohort. Reprod Health 2018; 15:54.^,77. Raj A, Dey A, Boyce S, Seth A, Bora S, Chandurkar D, et al. Associations between mistreatment by a provider during childbirth and maternal health complications in Uttar Pradesh, India. Matern Child Health J 2017; 21:1821-33.^,88. Kujawski S, Mbaruku G, Freedman LP, Ramsey K, Moyo W, Kruk ME. Association between disrespect and abuse during childbirth and women's confidence in health facilities in Tanzania. Matern Child Health J 2015; 19:2243-50.^,99. Minckas N, Gram L, Smith C, Mannell J. Disrespect and abuse as a predictor of postnatal care utilization and maternal-newborn well-being: a mixed-methods systematic review. BMJ Glob Health 2021; 6:e004698.^,1010. Hajizadeh K, Mirghafourvand M. Relationship of post-traumatic stress disorder with disrespect and abuse during childbirth in a group of Iranian postpartum women: a prospective study. Ann Gen Psychiatry 2021; 20:8.. This practice can be expressed via physical, sexual and verbal abuse, discrimination based on sociodemographic characteristics, non-compliance with recommended professional norms (lack of informed consent and confidentiality, physical examination and procedures, neglect and abandonment), inadequate relationships between women and health professionals, and health system conditions and restrictions ¹¹11. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, More JPSS, et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med 2015; 12:e1001847..

Although a serious violation of human rights, disrespect and abuse during childbirth affects many women in health institutions worldwide ¹²12. World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth. Genebra: World Health Organization; 2014.. A cross-sectional study conducted in India in 2016 identified that 77.3% of the 875 respondents experienced some type of disrespect and abuse during childbirth ¹³13. Dey A, Shakya HB, Chandurkar D, Kumar S, Das AK, Anthony J, et al. Discordance in self-report and observation data on mistreatment of women by providers during childbirth in Uttar Pradesh, India. Reprod Health 2017; 14:149.. In Latin America, a systematic review conducted with 18 studies showed that the prevalence of disrespect and abuse during childbirth in the region corresponded to 43% ⁵5. Tobasía-Hege C, Pinart M, Madeira S, Guedes A, Reveiz L, Valdez-Santiago R, et al. Irrespeto y maltrato durante o parto e o aborto na América Latina: revisão sistemática y metaanálisis. Rev Panam Salud Pública 2019; 43:e36.. In Brazil, a national hospital-based survey of 23,940 women ¹⁴14. d'Orsi E, Brüggemann OM, Diniz SCG, Aguiar JM, Gusnan CR, Torres JA, et al. Desigualdades sociais e satisfação das mulheres com o atendimento ao parto no Brasil: estudo nacional de base hospitalar. Cad Saúde Pública 2014; 30 Suppl 1:S154-68., conducted in 2011/2012, interviewed 15,688 of them by telephone. The study estimated that the prevalence of physical, verbal, or psychological violence during childbirth was 5.9%, more frequent among mixed-race or black women, with less schooling and living in the Northeast Region. Another population-based study with 4,000 women in Pelotas (Rio Grande do Sul State) ⁶6. Mesenburg MA, Victora CG, Jacob Serruya S, Ponce de León R, Damaso AH, Domingues MR, et al. Disrespect and abuse of women during the process of childbirth in the 2015 Pelotas birth cohort. Reprod Health 2018; 15:54., showed that 18.5% of them reported some type of disrespect and abuse during childbirth, 10% of which experienced verbal abuse and 5%, physical abuse.

Disrespect and abuse during childbirth experiences can result in numerous negative consequences, such as higher probability of complications and lower satisfaction with childbirth ⁷7. Raj A, Dey A, Boyce S, Seth A, Bora S, Chandurkar D, et al. Associations between mistreatment by a provider during childbirth and maternal health complications in Uttar Pradesh, India. Matern Child Health J 2017; 21:1821-33., reduced trust in health units ⁸8. Kujawski S, Mbaruku G, Freedman LP, Ramsey K, Moyo W, Kruk ME. Association between disrespect and abuse during childbirth and women's confidence in health facilities in Tanzania. Matern Child Health J 2015; 19:2243-50. and less involvement of women with maternal and neonatal health care ⁹9. Minckas N, Gram L, Smith C, Mannell J. Disrespect and abuse as a predictor of postnatal care utilization and maternal-newborn well-being: a mixed-methods systematic review. BMJ Glob Health 2021; 6:e004698.. Moreover, traumatic situations during childbirth also exhibit an association with a higher risk of mental health problems, such as anxiety, post-traumatic stress, and postpartum depression ⁹9. Minckas N, Gram L, Smith C, Mannell J. Disrespect and abuse as a predictor of postnatal care utilization and maternal-newborn well-being: a mixed-methods systematic review. BMJ Glob Health 2021; 6:e004698.^,1010. Hajizadeh K, Mirghafourvand M. Relationship of post-traumatic stress disorder with disrespect and abuse during childbirth in a group of Iranian postpartum women: a prospective study. Ann Gen Psychiatry 2021; 20:8.^,1515. Reed R, Sharman R, Inglis C. Women's descriptions of childbirth trauma relating to care provider actions. BMC Pregancy Childbirth 2017; 17:21.. Not receiving adequate information, feeling physical pain, being submitted to procedures without consent, and experiencing negative interactions with health professionals during childbirth increase the chance of women developing postpartum depressive symptoms ¹⁵15. Reed R, Sharman R, Inglis C. Women's descriptions of childbirth trauma relating to care provider actions. BMC Pregancy Childbirth 2017; 17:21.^,1616. Elmir R, Schmied V, Wilkes L, Jackson D. Women's perceptions and experiences of a traumatic birth: a meta-ethnography. J Adv Nurs 2010; 66:2142-53.^,1717. Harris R, Ayers S. What makes a labour and birth traumatic? A survey of intrapartum 'hotspots'. Psychol Health 2012; 27:1166-77..

Postpartum depression is a form of depressive disorder that occurs in the first year after childbirth ¹⁸18. American Psychiatric Association. Manual diagnóstico e estatístico de transtornos mentais: DSM-5. Porto Alegre: Artmed; 2014.^,1919. Moraes GP, Lorenzo L, Pontes GA, Montenegro MC, Cantilino A. Screening and diagnosing postpartum depression: when and how? Trends Psychiatry Psychother 2017; 39:54-61., affecting 17.2% of women worldwide ²⁰20. Wang Z, Liu J, Shuai H, Cai Z, Fu X, Liu Y, et al. Mapping global prevalence of depression among postpartum women. Transl Psychiatry 2021; 11:543.. However, most studies on prevalence do not allow us to state whether postpartum depression is a new occurrence or a continuation of a condition prior to pregnancy ²¹21. Shorey S, Chee CYI, Ng ED, Chan VH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: a systematic review and meta-analysis. J Psychiatr Res 2018; 104:235-48.^,2222. Santi S, Mauri M, Oppo A, Borri C, Rambelli C, Ramacciotti D, et al. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset depression. Results from perinatal depression - research & screening unit study. Compr Psychiatry 2011; 52:343-51.. The most common symptoms include depressed mood, sleep disturbances, loss of energy, feelings of guilt, irritability, anxiety, and suicidal ideations ²³23. Quevedo J, Nardi AE, Silva AG. Depressão: teoria e clínica. Porto Alegre: Artmed; 2018.. Moreover, postpartum depression can negatively interfere in the interaction between mother and baby ²⁴24. Hakanen H, Flykt M, Sinervä E, Nolvi S, Kataja EL, Pelto J, et al. How maternal pre- and postnatal symptoms of depression and anxiety affect early mother-infant interaction? J Affect Disord 2019; 257:83-90., favor the early interruption of breastfeeding ²⁵25. Silva CS, Lima MC, Sequeira-de-Andrade LAS, Oliveira JS, Monteiro JS, Lima NMS, et al. Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life. J Pediatr 2017; 93:356-64., cause growth problems ²⁶26. Farías-Antúnez S, Xavier MO, Santos IS. Effect of maternal postpartum depression on offspring's growth. J Affect Disord 2018; 228:143-52., and contribute to cognitive/behavioral changes in children whose mothers presented symptoms of postpartum depression ²⁷27. Netsi E, Pearson RM, Murray L, Cooper P, Craske MG, Stein A. Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry 2018; 75:247-53.^,2828. Kingston D, Kehler H, Austin MP, Mughal MK, Wajid A, Vermeyden L, et al. Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years. PLoS One 2018; 13:e0195365..

Some primary studies on the relationship of disrespect and abuse during childbirth and the occurrence of postpartum depression have been published, but a preliminary search in PROSPERO, MEDLINE (PubMed), Cochrane Library, and Joanna Briggs Institute (JBI) did not identify any current or ongoing scoping or systematic review, thus justifying the production of this review.

This review was conducted with the aim to map, in the scientific literature, the relationship between disrespect and abuse in childbirth and the occurrence of postpartum depression.

Methods

This scoping review was prepared according to the six methodological steps recommended by the JBI: identification of the research question; identification of relevant studies; selection of studies; data extraction; separation, summarization, and reporting of results; and dissemination of results ²⁹29. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: scoping reviews. In: Aromataris E, Munn Z, editores. JBI manual for evidence synthesis. https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews.
https://jbi-global-wiki.refined.site/spa... . The checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) ³⁰30. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018; 169:467-73. was also used to guide the construction of this review.

The elaboration of the guiding question of the research was based on the mnemonic strategy PCC (population, concept, and context) ³¹31. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6:264-9., from which we established that “P” are women who suffered disrespect and abuse during childbirth, “C” is postpartum depression, and “C” is the period after childbirth. The original research question was as follows: what is the relationship between disrespect and abuse during childbirth and the occurrence of postpartum depression?

To identify the relevant studies, the search was carried out from May to June 2022 and updated in January 2023, by two independent reviewers, in the databases Embase, LILACS (via Virtual Health Library), MEDLINE (via PubMed), PsycINFO, Web of Science, and in the Portal of Theses and Dissertations of the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES).

The search strategy in the database was performed in three stages. In the first, a limited initial search in MEDLINE was performed using the descriptors related to PCC mnemonics, namely: “violence”, “parturition”, “childbirth”, and “depression postpartum”, according to the standardized and indexed terms in the Medical Subject Headings (MeSH), in order to verify the words present in the title and abstract of the relevant articles and indexing terms. In the second stage, the identified words and indexing terms were associated with the descriptors using the Boolean operators “AND” and “OR”, giving rise to different strategies in each database (Box 1). In the third stage, the reference list of all studies included in the review was analyzed.

The inclusion criteria were studies that investigated the relationship between disrespect and abuse during childbirth with postpartum depression, according to diagnosis by physicians and by self-reports via validated scales. No restrictions were defined regarding the year of publication and the language. Duplicate studies, opinion pieces, studies in which the full-text was not available and those that did not demonstrate the results of the research were excluded.

For the selection process, all the studies found were transported to the online EndNote software (http://www.endnote.com/), thus excluding the duplicates. The selection was then carried out in two stages: first, the titles and abstracts were read; second, the texts were read in full. After reading of titles and abstracts, studies that met the inclusion criteria and those in which it was not possible, via the title and abstract alone, to identify whether the relationship between disrespect and abuse during childbirth and postpartum depression was investigated were selected for the next phase. With the reading of the texts in full, the studies that analyzed the relationship between disrespect and abuse during childbirth and postpartum depression and that demonstrated the results of this investigation were selected. The selection process was made by two independent reviewers, with the help of the Rayyan QCR software application (https://www.rayyan.ai/). Disagreements were resolved by consulting a third reviewer.

Data extraction was guided by a form prepared jointly by the authors, which included the following data: author/year of publication; country of study; type of study; objective of the study; study population/sample size; instrument to assess disrespect and abuse during childbirth; instrument for the evaluation of postpartum depression; self-reported disrespect and abuse during childbirth types and main outcomes. The extracted data were presented in boxes, accompanied by a narrative summary.

Results

A total of 3,399 publications were identified, of which 221 were duplicates. Of the 3,178 documents obtained, 3,125 were excluded after reading the titles and abstracts, resulting in a sample of 53 publications. After a full reading, 7 articles were selected to integrate this review (Figure 1).

When characterizing the studies according to year, a higher frequency of the year 2022 was observed, totaling 4 (57.1%) publications. The remaining studies were published in 2017, 2019, and 2020. Most studies were conducted in Brazil, with 4 (57.1%) publications, the remaining 3 (42.9%) were from another country (Argentina, Spain, and Russia). The predominant type of study was cross-sectional, with 5 (71.4%) publications, the other 2 (28.6%) were cohort studies (Box 2).

The instruments used to assess disrespect and abuse during childbirth were different for each of the studies analyzed, since they were elaborated by the authors of the research ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.^,3333. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.^,3434. Leite TH, Pereira APE, Leal MC, Silva AM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401.^,3535. Martinez-Vázquez S, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M, Martínez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: an observational study. Midwifery 2022; 108:103297.^,3636. Paiz JC, Castro SMJ, Giugliani ERJ, Ahne SMS, Dall'Aqua CB, Giugliani C. Association between mistreatment of women during childbirth and symptoms of postpartum depression. BMC Pregnancy Childbirth 2022; 22:664.^,3737. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480.^,3838. Yakupova V, Suarez A, Karchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. Int J Environ Res Public Health 2022; 19:335.. All studies evaluated postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.^,3333. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.^,3434. Leite TH, Pereira APE, Leal MC, Silva AM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401.^,3535. Martinez-Vázquez S, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M, Martínez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: an observational study. Midwifery 2022; 108:103297.^,3636. Paiz JC, Castro SMJ, Giugliani ERJ, Ahne SMS, Dall'Aqua CB, Giugliani C. Association between mistreatment of women during childbirth and symptoms of postpartum depression. BMC Pregnancy Childbirth 2022; 22:664.^,3737. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480.^,3838. Yakupova V, Suarez A, Karchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. Int J Environ Res Public Health 2022; 19:335., and one of them used the short version of the scale, the EPDS-6 ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.. In addition to the EPDS, one study also applied the Mini International Neuropsychiatric Interview (MINI) ³⁷37. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480. (Box 3).

Regarding the types of disrespect and abuse during childbirth reported by the women, we identified the lack of a companion during childbirth ³⁶36. Paiz JC, Castro SMJ, Giugliani ERJ, Ahne SMS, Dall'Aqua CB, Giugliani C. Association between mistreatment of women during childbirth and symptoms of postpartum depression. BMC Pregnancy Childbirth 2022; 22:664., painful vaginal examinations, inadequate pain relief, poor care, lack of communication/insufficient explanations by the professional regarding the obstetric procedures performed and use of offensive language by health professionals during childbirth ³², lack of privacy and reception, not having felt safe in the childbirth environment, and not having felt comfortable asking questions and participating in decisions about their care ³⁶36. Paiz JC, Castro SMJ, Giugliani ERJ, Ahne SMS, Dall'Aqua CB, Giugliani C. Association between mistreatment of women during childbirth and symptoms of postpartum depression. BMC Pregnancy Childbirth 2022; 22:664.. Verbal ³⁸38. Yakupova V, Suarez A, Karchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. Int J Environ Res Public Health 2022; 19:335. and/or physical abuse, refusal of care, and unwanted procedures during childbirth were also reported ³³33. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.^,3535. Martinez-Vázquez S, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M, Martínez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: an observational study. Midwifery 2022; 108:103297.^,3737. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480.. In addition to these forms of disrespect and abuse during childbirth, a study demonstrated that, in the public health sector, disrespect and abuse during childbirth was related to maternal hospitalization, uterine pressure maneuver and not receiving the desired type of delivery; while in the private sector, not having the desired mode of delivery was the type of disrespectful and abusive care reported ³⁴34. Leite TH, Pereira APE, Leal MC, Silva AM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401. (Box 3).

All studies showed that disrespect and abuse during childbirth was associated with a higher occurrence of postpartum depression symptoms ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.^,3333. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.^,3434. Leite TH, Pereira APE, Leal MC, Silva AM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401.^,3535. Martinez-Vázquez S, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M, Martínez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: an observational study. Midwifery 2022; 108:103297.^,3636. Paiz JC, Castro SMJ, Giugliani ERJ, Ahne SMS, Dall'Aqua CB, Giugliani C. Association between mistreatment of women during childbirth and symptoms of postpartum depression. BMC Pregnancy Childbirth 2022; 22:664.^,3737. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480.^,3838. Yakupova V, Suarez A, Karchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. Int J Environ Res Public Health 2022; 19:335.. One study demonstrated that abuse and lack of a companion during childbirth were significantly associated with a higher risk of postpartum depression ³⁷37. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480.. In another investigation, women who suffered psycho-affective or verbal obstetric violence were more prone to postpartum depression ³⁵35. Martinez-Vázquez S, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M, Martínez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: an observational study. Midwifery 2022; 108:103297..

Symptoms of postpartum depression were higher in women submitted to more forms of disrespect and abuse during childbirth ³⁸38. Yakupova V, Suarez A, Karchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. Int J Environ Res Public Health 2022; 19:335.. Women who reported at least one type of disrespect and abuse during childbirth were 1.6 times more likely to have postpartum depression, while those who experienced three or more types of disrespect and abuse during childbirth were almost 3 and 4 times more likely to have postpartum depression symptoms, respectively ³³33. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.. Higher measures of association were found in another study, in which women who were subjected to neglection violence during childbirth were 7 times more likely to develop postpartum depression when compared to women who did not suffer from disrespectful and abusive assistance ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.. In turn, disrespect and abuse during childbirth was associated with postpartum depression in both the public and private health sectors ³⁴34. Leite TH, Pereira APE, Leal MC, Silva AM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401. (Box 3).

Discussion

This scoping review, although without restriction of language and year of publication, found studies only from 2017 and only in 4 countries (Argentina, Brazil, Spain, and Russia), reflecting the scarcity of research in the world on this very relevant theme.

Some of the most frequent types of disrespect and abuse during childbirth were the impediment of a companion during childbirth, not feeling safe in the delivery environment, and, mainly, inadequate relationships between professionals and women (painful vaginal examinations, inadequate pain relief, care considered poor, lack of communication and explanations by the professional regarding the obstetric procedures performed, unwanted procedures, refusal of care, not having the desired mode of delivery and verbal, physical, and psycho-affective abuse) ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.^,3333. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.^,3434. Leite TH, Pereira APE, Leal MC, Silva AM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401.^,3535. Martinez-Vázquez S, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M, Martínez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: an observational study. Midwifery 2022; 108:103297.^,3636. Paiz JC, Castro SMJ, Giugliani ERJ, Ahne SMS, Dall'Aqua CB, Giugliani C. Association between mistreatment of women during childbirth and symptoms of postpartum depression. BMC Pregnancy Childbirth 2022; 22:664.^,3737. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480.^,3838. Yakupova V, Suarez A, Karchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. Int J Environ Res Public Health 2022; 19:335.. These forms of disrespect and abuse during childbirth have also been identified in other studies ³⁹39. Carvalho IS, Brito RS. Formas de violência obstétrica vivenciadas por puérperas que tiveram parto normal. Enferm Glob 2017; 16:80-8.^,4040. Oluoch-Aridi J, Smith-Oka V, Milan E, Dowd R. Exploring mistreatment of women during childbirth in a peri-urban setting in Kenya: experiences and perceptions of women and healthcare providers. Reprod Health 2018; 15:209.^,4141. Galle A, Manaharlal H, Cumbane E. Disrespect and abuse during facility-based childbirth in Southern Mozambique: a cross-sectional study. BMC Pregnancy Childbirth 2019; 19:369.. These reports contradict the recommendations of the World Health Organization (WHO), which emphasizes the right of women to empathetic support from service providers, the presence of a companion, and the provision of all the information and explanations they wish during labor/delivery ⁴²42. World Health Organization. Care in normal birth: a pratical guide. Genebra: World Health Organization; 1996..

The studies included in this review evaluated disrespectful and abusive childbirth care using different instruments ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.^,3333. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.^,3434. Leite TH, Pereira APE, Leal MC, Silva AM. Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study. J Affect Disord 2020; 273:391-401.^,3535. Martinez-Vázquez S, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M, Martínez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: an observational study. Midwifery 2022; 108:103297.^,3636. Paiz JC, Castro SMJ, Giugliani ERJ, Ahne SMS, Dall'Aqua CB, Giugliani C. Association between mistreatment of women during childbirth and symptoms of postpartum depression. BMC Pregnancy Childbirth 2022; 22:664.^,3737. Puppo S, Cormick G, Gibbons L, Rodríguez R, Correa M, Smith J, et al. The peripartum period involvement in the development of post-partum depression: a prospective cohort study. J Psychosom Res 2022; 155:1107480.^,3838. Yakupova V, Suarez A, Karchenko A. Birth experience, postpartum PTSD and depression before and during the pandemic of COVID-19 in Russia. Int J Environ Res Public Health 2022; 19:335.. In 2014, the WHO published a document recommending the development of research to measure disrespect and abuse during childbirth ¹²12. World Health Organization. The prevention and elimination of disrespect and abuse during facility-based childbirth. Genebra: World Health Organization; 2014.. Since then, validated measurement tools have been proposed, as well as some forms developed by authors who sought to investigate the occurrence of disrespect and abuse during childbirth ¹1. Diniz SG, Salgado HO, Andrezzo HFA, Carvalho PGC, Carvalho PCAC, Aguiar CA, et al. Violência obstétrica como questão para a saúde pública no Brasil: origens, definições, tipologia, impactos sobre a saúde materna, e propostas para sua prevenção. J Hum Growth Dev 2015; 25:377-84-8.^,77. Raj A, Dey A, Boyce S, Seth A, Bora S, Chandurkar D, et al. Associations between mistreatment by a provider during childbirth and maternal health complications in Uttar Pradesh, India. Matern Child Health J 2017; 21:1821-33.^,4141. Galle A, Manaharlal H, Cumbane E. Disrespect and abuse during facility-based childbirth in Southern Mozambique: a cross-sectional study. BMC Pregnancy Childbirth 2019; 19:369.^,4343. Abuya T, Ndwiga C, Ritter J, Kanya L, Bellows B, Binkin N, et al. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC Pregnancy Childbirth 2015; 15:224.^,4444. Andrade PON, Silva JQP, Diniz CMM, Caminha MFC. Fatores associados à violência obstétrica na assistência ao parto vaginal em uma maternidade de alta complexidade em Recife, Pernambuco. Rev Bras Saúde Matern Infant 2016; 16:29-37.^,4545. Bohren MA, Vogel JP, Fawole B, Maya ET, Maung TM, Baldé MD, et al. Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey. BMC Med Res Methodol 2018; 18:132.^,4646. Kruk ME, Kujawski S, Mbaruku G, Ramsey K, Moyo W, Freedman LP. Disrespectful and abusive treatment during facility delivery in Tanzania: a facility and community survey. Health Policy Plan 2018; 33:e26-33.. Nevertheless, even one of the most popular instruments, proposed by Bohren et al. ⁴⁵45. Bohren MA, Vogel JP, Fawole B, Maya ET, Maung TM, Baldé MD, et al. Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey. BMC Med Res Methodol 2018; 18:132., presents significant limitations, such as the non-investigation of sexual violence; thus, there is still no universally accepted instrument for measuring disrespect and abuse during childbirth ⁴4. Leite TH, Marques ES, Esteves-Pereira AP, Nucci MF, Portella Y, Leal MC. Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil. Ciênc Saúde Colet 2022; 27:483-91..

The absence of such tool, combined with the lack of a standardized term for this type of care, is an obstacle to estimate the prevalence, risk factors, consequences of these abuses, and it hinders the comparison of results among the available studies on the subject ⁴4. Leite TH, Marques ES, Esteves-Pereira AP, Nucci MF, Portella Y, Leal MC. Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil. Ciênc Saúde Colet 2022; 27:483-91.. Some of the other nomenclatures used to name this phenomenon, in addition to disrespect and abuse during childbirth, includes mistreatment of women during childbirth, institutional gender violence during childbirth, inhuman/dehumanized care, and obstetric violence ²2. Tesser CD. Violência obstétrica e prevenção quaternária: o que é e o que fazer. Rev Bras Med Fam Comunidade 2015; 10:1-12.^,33. Sadler M, Santos MJ, Ruiz-Berdún D, Rojas GL, Skoko E, Gillen P, et al. Moving beyond disrespect and abuse: addressing the structural dimensions of obstetric violence. Reprod Health Matters 2016; 24:47-55.^,44. Leite TH, Marques ES, Esteves-Pereira AP, Nucci MF, Portella Y, Leal MC. Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil. Ciênc Saúde Colet 2022; 27:483-91.^,4747. Katz L, Amorim MM, Giordano JC, Bastos MH, Brilhante AVM. Quem tem medo da violência obstétrica? Rev Bras Saúde Matern Infant 2020; 20:627-31.. Well known to the general public, the terminology obstetric violence is the target of criticism, especially from health professionals, who argue that some practices considered as violence are routine procedures for childbirth care. Additionally, the word “obstetric” may be erroneously associated with the exclusive conduct of the medical professional, disregarding the attitudes of other health professionals and the structure of the institution in which the delivery occurs ⁴4. Leite TH, Marques ES, Esteves-Pereira AP, Nucci MF, Portella Y, Leal MC. Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil. Ciênc Saúde Colet 2022; 27:483-91.^,4848. Asefa A, Bekele D. Status of respectful and non-abusive care during facility-based childbirth in a hospital and health centers in Addis Ababa, Ethiopia. Reprod Health 2015; 12:33..

The findings also showed that women who suffered disrespect and abuse during childbirth during childbirth were more likely to have symptoms of postpartum depression, with a 1.6- to 7-fold increase in risk ³²32. Souza KJ, Rattner D, Gubert MB. Institutional violence and quality of service in obstetrics are associated with postpartum depression. Rev Saúde Pública 2017; 51:69.^,3333. Silveira MF, Mesenburg MA, Bertoldi AD, Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: findings from the 2015 Pelotas birth cohort study. J Affect Disord 2019; 256:441-7.. The literature has few studies that can be compared with these results, since most studies investigate the types and prevalence of disrespect and abuse during childbirth ⁴¹41. Galle A, Manaharlal H, Cumbane E. Disrespect and abuse during facility-based childbirth in Southern Mozambique: a cross-sectional study. BMC Pregnancy Childbirth 2019; 19:369.^,4343. Abuya T, Ndwiga C, Ritter J, Kanya L, Bellows B, Binkin N, et al. The effect of a multi-component intervention on disrespect and abuse during childbirth in Kenya. BMC Pregnancy Childbirth 2015; 15:224.^,4848. Asefa A, Bekele D. Status of respectful and non-abusive care during facility-based childbirth in a hospital and health centers in Addis Ababa, Ethiopia. Reprod Health 2015; 12:33.^,4949. Madeiro A, Rufino AC, Acaqui RF, Barbosa CM, Martins VMML, Sousa AMC. Disrespect and abuse during childbirth in maternity hospitals in Piauí, Brazil: a cross-sectional study. Int J Gynecol Obstet 2022; 159:961-7., and there are few studies that analyze its consequences ⁴4. Leite TH, Marques ES, Esteves-Pereira AP, Nucci MF, Portella Y, Leal MC. Desrespeitos e abusos, maus tratos e violência obstétrica: um desafio para a epidemiologia e a saúde pública no Brasil. Ciênc Saúde Colet 2022; 27:483-91.. However, corroborating the association identified in this review, a cross-sectional study conducted in Southern Brazil ⁵⁰50. Hartmann JM, Mendoza-Sassi RA, Cesar JA. Depressão entre puérperas: prevalência e fatores associados. Cad Saúde Pública 2017; 33:e00094016., with 2,687 postpartum women, showed that the support of professionals during childbirth decreased the risk of postpartum depression by 23%. On the other hand, lack of information about the procedures, lack of participation of the women in decision-making regarding childbirth, and inhuman/disrespectful treatment are contributing factors to the negative or traumatic experiences of childbirth ¹⁶16. Elmir R, Schmied V, Wilkes L, Jackson D. Women's perceptions and experiences of a traumatic birth: a meta-ethnography. J Adv Nurs 2010; 66:2142-53., contributing to the occurrence of psychological suffering such as postpartum depression ⁵¹51. Bell AF, Andersson E. The birth experience and women's postnatal depression: a systematic review. Midwifery 2016; 39:112-23..

Despite the association observed in this study, it is necessary to be cautious when analyzing the results, considering that the EPDS, used in the included studies to evaluate postpartum depression, is a tool for screening for postpartum depression, not for diagnosis ⁵²52. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 50:782-6.. Moreover, the occurrence of the disorder may be related to other factors, other than disrespect and abuse during childbirth, such as a history of depression, low social support, unplanned or unwanted pregnancy, domestic violence, stressful life events, poor marital relationship, and financial difficulties ²⁰20. Wang Z, Liu J, Shuai H, Cai Z, Fu X, Liu Y, et al. Mapping global prevalence of depression among postpartum women. Transl Psychiatry 2021; 11:543.^,5353. Norhayati MN, Hazlina NH, Asrenee AR, Emilin WM. Magnitude and risk factors for postpartum symptoms: a literature review. J Affect Disord 2015; 175:34-52..

We emphasize that this review has limitations that should be considered. First, the search strategy employed may not have been sufficiently comprehensive to identify all the available content on the subject, considering that there is a lack of consensus in the definition for disrespectful and abusive care during childbirth. Also, the included studies used different instruments to assess disrespect and abuse during childbirth, which may have interfered in the association. Finally, the occurrence of postpartum depression and disrespect and abuse during childbirth were investigated with instruments based on the self-reports of the participants, which favors memory bias. However, the scientific gap identified in this review may encourage the development of future research. Our results may contribute to the body of literature on this topic, as well as reinforce the need for a terminology and universal assessment instrument for disrespectful and abusive care during childbirth.

Conclusion

The results of this study suggest that disrespect and abuse during childbirth is associated with increased risk for the development of postpartum depression. The findings also showed a lack of scientific research on the subject. We recommend for further investigations on the relationship between disrespect and abuse during childbirth and postpartum depression to be carried out, considering that the identification of risk factors for postpartum depression may help in the development of strategies to reduce the occurrence of this disorder.

References

Publication Dates

History