Mistreatment during facility-based childbirth in Benin City, Nigeria: A convergent mixed-methods study of prevalence and drivers

Abstract

Abstract Background Mistreatment during facility-based childbirth undermines maternal health outcomes and trust in health systems, particularly in low- and middle-income countries. Nigeria bears one of the highest global burdens of maternal mortality, yet limited large-scale mixed-methods studies have examined how mistreatment is both experienced by women and shaped by health system conditions. This study assessed the prevalence, forms, and drivers of mistreatment during childbirth in Benin City, Nigeria, integrating women’s and skilled birth attendants’ (SBAs) perspectives. Methods We conducted a convergent parallel mixed-methods study between July–August 2024 across three healthcare facilities (tertiary, secondary, and private) in Benin City. Postpartum women (≤ 12 months since delivery) completed a 45-item mistreatment survey ( n = 656). Mistreatment was categorized across eight domains. Descriptive statistics and chi-square analyses were performed. In-depth interviews were conducted with postpartum women ( n = 20), and four focus group discussions were held with SBAs ( n = 26). Qualitative data were analyzed using constructivist grounded theory. Findings were integrated using a joint display matrix to assess convergence, divergence, and complementarity. Results Overall, 89.5% of women reported experiencing at least one form of mistreatment, though only 2.6% labeled their experience as mistreatment. The most common domains were undignified care (70%) and loss of autonomy (48.2%), followed by physical abuse (37.5%) and abandonment (16.3%). Vaginal delivery, higher education, and antenatal care attendance were significantly associated with reported mistreatment ( p < 0.05). Qualitative analysis identified five themes: divergent expectations between women and SBAs; shared labeling of laboring women as “uncooperative”; inconsistent definitions of mistreatment; provider burnout; and structural constraints including understaffing, limited infrastructure, and financial barriers. Both groups used the term “uncooperative” to describe laboring behavior, though with different interpretations. Women emphasized disrespect, lack of consent, and loss of autonomy, while SBAs contextualized care within systemic constraints and workload pressures. Integration showed strong convergence between quantitative autonomy violations and qualitative accounts of restricted companionship, hierarchical communication, and limited shared decision-making. Comclusions Mistreatment during childbirth in urban Nigeria is highly prevalent and sustained by intersecting interpersonal and structural health system factors. Efforts to improve maternal health outcomes must address workforce capacity, institutional norms, accountability mechanisms, and rights-based antenatal education to ensure that clinical safety and respectful maternity care are jointly prioritized.