abstract: 'Background Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. Methods We prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment. Findings 2016 labour observations and 2672 surveys were done. 838 (41.6\%) of 2016 observed women and 945 (35.4\%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 {[}75.1\%] of 253; survey: 295 {[}56.1\%] of 526) or caesarean section (observation: 35 {[}13.4\%] of 261; survey: 52 {[}10.8\%] of 483), despite receiving these procedures. 133 (5.0\%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15-19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio {[}OR] 3.6, 95\% CI 1 .6-8.0) and younger women with some education (OR 1.6, 1.1-2.3) were more likely to experience verbal abuse, compared with older women (>= 30 years), adjusting for marital status and parity. Interpretation More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context. Copyright (C) 2019 This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.' affiliation: 'Bohren, MA (Corresponding Author), Univ Melbourne, Melbourne Sch Populat \& Global Hlth, Ctr Hlth Equ, Gender \& Womens Hlth Unit, Carlton, Vic 3053, Australia. Bohren, Meghan A., Univ Melbourne, Melbourne Sch Populat \& Global Hlth, Ctr Hlth Equ, Gender \& Womens Hlth Unit, Carlton, Vic 3053, Australia. Bohren, Meghan A.; Mehrtash, Hedieh; Thwin, Soe Soe; Landoulsi, Sihem; Gulmezoglu, A. Metin; Tuncalp, Ozge, WHO, UNDP UNFPA UNICEF WHO World Bank Special Programm, Dept Reprod Hlth \& Res, Geneva, Switzerland. Fawole, Bukola, Univ Ibadan, Dept Obstet \& Gynaecol, Natl Inst Maternal \& Child Hlth, Coll Med, Ibadan, Nigeria. Maung, Thae Maung; Mon, Nwe Oo, Dept Med Res, Yangon, Myanmar. Balde, Mamadou Dioulde; Diallo, Boubacar Alpha; Soumah, Anne-Marie; Sall, Alpha Oumar, Cellule Rech Sante Reprod Guinee CERREGUI, Conakry, Guinea. Maya, Ernest, Univ Ghana, Sch Publ Hlth, Dept Populat Family \& Reprod Hlth, Legon, Ghana. Aderoba, Adeniyi K., Mother \& Child Hosp, Dept Obstet \& Gynaecol, Akure, Ondo State, Nigeria. Vogel, Joshua P., Burnet Inst, Maternal \& Child Hlth Program, Melbourne, Vic, Australia. Irinyenikan, Theresa Azonima, Univ Med Sci Ondo, Fac Clin Sci, Dept Obstet \& Gynaecol, Ondo, Ondo State, Nigeria. Irinyenikan, Theresa Azonima, Univ Med Sci, Teaching Hosp, Akure, Ondo State, Nigeria. Adeyanju, A. Olusoji, Adeoyo Matern Teaching Hosp, Ibadan, Oyo State, Nigeria. Adu-Bonsaffoh, Kwame, Univ Ghana, Sch Med \& Dent, Dept Obstet \& Gynaecol, Accra, Ghana. Guure, Chris, Univ Ghana, Sch Publ Hlth, Dept Biostat, Legon, Ghana. Adanu, Richard, Univ Ghana, Sch Publ Hlth, Legon, Ghana.' author: Bohren, Meghan A. and Mehrtash, Hedieh and Fawole, Bukola and Maung, Thae Maung and Balde, Mamadou Dioulde and Maya, Ernest and Thwin, Soe Soe and Aderoba, Adeniyi K. and Vogel, Joshua P. and Irinyenikan, Theresa Azonima and Adeyanju, A. Olusoji and Mon, Nwe Oo and Adu-Bonsaffoh, Kwame and Landoulsi, Sihem and Guure, Chris and Adanu, Richard and Diallo, Boubacar Alpha and Gulmezoglu, A. Metin and Soumah, Anne-Marie and Sall, Alpha Oumar and Tuncalp, Ozge author-email: meghan.bohren@unimelb.edu.au author_list: - family: Bohren given: Meghan A. - family: Mehrtash given: Hedieh - family: Fawole given: Bukola - family: Maung given: Thae Maung - family: Balde given: Mamadou Dioulde - family: Maya given: Ernest - family: Thwin given: Soe Soe - family: Aderoba given: Adeniyi K. - family: Vogel given: Joshua P. - family: Irinyenikan given: Theresa Azonima - family: Adeyanju given: A. Olusoji - family: Mon given: Nwe Oo - family: Adu-Bonsaffoh given: Kwame - family: Landoulsi given: Sihem - family: Guure given: Chris - family: Adanu given: Richard - family: Diallo given: Boubacar Alpha - family: Gulmezoglu given: A. Metin - family: Soumah given: Anne-Marie - family: Sall given: Alpha Oumar - family: Tuncalp given: Ozge da: '2023-09-28' doi: 10.1016/S0140-6736(19)31992-0 eissn: 1474-547X esi-highly-cited-paper: Y esi-hot-paper: N files: [] issn: 0140-6736 journal: LANCET keywords-plus: DISRESPECT; ABUSE; CARE; MISTREATMENT; QUALITY language: English month: NOV 9 number: '10210' number-of-cited-references: '49' orcid-numbers: 'Maya, Ernest Tei/0000-0001-6050-6837 Adu-Bonsaffoh, Kwame/0000-0002-3741-6646 ADEROBA, Adeniyi Kolade/0000-0002-4333-9093 Vogel, Joshua/0000-0002-3214-7096 Maung, Thae Maung/0000-0002-1265-3813 Tunçalp, Ӧzge/0000-0002-5370-682X Mehrtash, Hedieh/0000-0003-4991-616X Mon, Nwe Oo/0000-0001-5432-6880 Bohren, Meghan/0000-0002-4179-4682' pages: 1750-1763 papis_id: 073e13aaf56790ea6edfad7ec9d57cfd ref: Bohren2019howwomen researcherid-numbers: 'Maya, Ernest Tei/T-2576-2019 Adu-Bonsaffoh, Kwame/AAH-5560-2020 ADEROBA, Adeniyi Kolade/AAU-1426-2021 Vogel, Joshua/K-7649-2019 Maung, Thae Maung/S-2495-2018 Tunçalp, Ӧzge/Y-2724-2018 ' times-cited: '203' title: 'How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys' type: Article unique-id: WOS:000496920300030 usage-count-last-180-days: '3' usage-count-since-2013: '37' volume: '394' web-of-science-categories: Medicine, General \& Internal year: '2019'