key: cord-0330135-k2l35v3f authors: Meyer, S.; Cignacco, E.; Monteverde, S.; Trachsel, M.; Raio, L.; Oelhafen, S. title: "We felt like part of a production system": a qualitative study on women's experience of mistreatment during childbirth in Switzerland date: 2021-06-08 journal: nan DOI: 10.1101/2021.06.07.21258295 sha: 28eda3746cffd27e98506c1d38b9da163714088d doc_id: 330135 cord_uid: k2l35v3f Introduction Mistreatment during childbirth is an issue of global magnitude that not only violates fundamental human rights but also seriously impacts women's well-being. The purpose of this study was to gain a better understanding of the phenomenon by exploring the individual experiences of women who reported mistreatment during childbirth in Switzerland. Materials and Methods This project used a mixed methods approach to investigate women's experiences of mistreatment during childbirth in general and informal coercion specifically: the present qualitative study expands on the findings from a nationwide online survey on childbirth experience. It combines inductive with theory-guided thematic analysis to study the 7753 comments women wrote in the survey and the subsequent interviews with 11 women who reported being mistreated during childbirth. Results The women described a wide range of experiences of mistreatment during childbirth in both the survey comments and the interviews. Out of all survey participants who wrote at least one comment (n = 3547), 28% described one or more experiences of mistreatment. Six of the seven types of mistreatment listed in Bohren and colleagues' typology of mistreatment during childbirth were found, the most frequent of which were ineffective communication and lack of informed consent. Five further themes were identified in the interviews: informal coercion, risk factors for mistreatment, consequences of mistreatment, examples of good care, and what's needed to improve maternity care. Conclusion The findings from this study show that experiences of mistreatment are a reality in Swiss maternity care and give insight into women's individual experiences as well as how these affect them during and after childbirth. This study emphasises the need to respect women's autonomy in order to prevent mistreatment and empower women to actively participate in decisions. Both individual and systemic efforts are required to prevent mistreatment and guarantee respectful, dignified, and high-quality maternity care for all. In recent years, the topic of mistreatment during childbirth has been gaining more and more attention: Women have started to speak out and share their negative experiences of maternity care, which in turn has sparked debate among the public, healthcare systems and the media and has resulted in political and legal change in several countries. A number of Latin American countries for instance have acknowledged obstetric violence as a form of gender-based violence and have passed laws to combat it, following the combined efforts of activists, governmental and non-governmental organisations and researchers, the first of which was Venezuela in 2007 [1] . However, mistreatment during childbirth continues to be a widespread problem around the world, including in high-income countries: Recent studies in Switzerland, Italy, Spain, the Netherlands and the US for instance have shown that a significant proportion of women report that they are mistreated by healthcare professionals (HCP) during childbirth [2] [3] [4] [5] [6] . Women have the right to safe, respectful and dignified obstetric care and any form of mistreatment violates fundamental human rights [7] [8] [9] [10] [11] . The World Health Organization (WHO) acknowledged the problem in 2015, when it issued a statement for the prevention and elimination of disrespect and abuse during facility-based childbirth in which it called for greater action, dialogue, research and advocacy on the matter [12] . Apart from violating fundamental human rights, mistreatment during childbirth can threaten women's mental health: negative or traumatic birth experiences are associated with post-traumatic stress disorder (PTSD) [e.g., 13, [14] [15] [16] [17] . A meta-analysis on risk factors of postpartum PTSD drew attention to the importance of women's experiences during birth, reporting an association between PTSD symptoms and low perceived quality of interactions with medical staff [18] . Reed, Sharman and Inglis found that traumatic birth experiences were most often connected to care provider actions and interactions: women reported that care providers prioritised their own agendas over the women's needs, disregarded women's own embodied knowledge, used lies and threats to coerce them into complying and violated them [19] . These findings indicate that rather than care providers' actions themselves, it is the way in which care providers carry these out that is traumatic. Post-partum PTSD can have serious long-term effects for women's physical, emotional and social well-being and has been shown to severely impair women's relationships with their partners and their children [20] . One difficulty in gaining a better understanding of and thereby preventing the phenomenon may be the variety of terminology used to describe it: mistreatment, obstetric violence, disrespect and abuse, dehumanised care, or coercion are often used more or less interchangeably depending on country, context, stakeholders and research methods, although each term emphasises different aspects of the issue [21] . Bohren, Vogel, Hunter, Lutsiv, Makh, Paulo Souza et al. recommend the term mistreatment of women during childbirth "as a broader, more inclusive term that better captures the full range of experiences women and healthcare providers have described in the literature" [22] . Their comprehensive, evidence-based typology of mistreatment is the result of a mixed methods systematic review of 65 studies from 34 countries. It encompasses the seven main themes physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers as well as health system conditions and constraints. The typology thereby includes both intentional and unintentional behaviours and acknowledges mistreatment as owing to both individual and structural issues. For these reasons, the present study adopted mistreatment as an umbrella term for violent, disrespectful, abusive, coercive or otherwise poor maternity care. So far, most studies investigating mistreatment during childbirth have focused on low-and middle-income countries, where the prevalence ranges between 20-77% [e.g., 23, [24] [25] [26] [27] . However, recent studies have shown comparable results in high-income countries. In Italy for instance, one in five participants in a nation-wide community-based survey considered themselves victims of obstetric violence [3] . As a result, many decided not to return to the same facility should they become pregnant again or even not to have any more children. Explicit requests for consent before medical procedures were negatively associated with reports of obstetric violence, a finding that highlights the importance of patient autonomy. In a Spanish study, more than a third of the participants indicated having suffered obstetric violence and nearly half reported that they underwent procedures for which they did not provide informed consent [4] . Women who reported obstetric violence were significantly less satisfied with the care they received. Several studies investigating mistreatment during childbirth in high-income countries used the typology by Bohren et al. A secondary qualitative analysis of a phenomenological study on birth trauma with women from New Zealand, the US, Australia and the UK identified six types of mistreatment, the most frequent of which was failure to meet professional standards of care, specifically being neglected and abandoned by HCP [28] . A cross-sectional online survey found that one in six US women experienced at least one type of mistreatment during childbirth, of which being shouted at or scolded by a HCP was the most commonly reported, followed by HCP ignoring women, refusing their requests for help or failing to respond to such requests in a reasonable amount of time . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint [6] . In the Netherlands, van der Pijl, Hollander, van der Linden, Verweij, Holten, Kingma et al. conducted a qualitative social media content analysis of negative or traumatic childbirth experiences shared by women in the #genoeggezwegen campaign (known as #breakthesilence or #rosesrevolution in English) [5] . The most common types of mistreatment were ineffective communication, loss of autonomy and lack of informed consent and confidentiality. In addition to mistreatment, their inductive analysis revealed a further five themes, such as not being taken seriously and not being listened to and short-and long-term consequences, as well as the overarching theme left powerless, which referred to a feeling of powerlessness both during birth and afterwards. The present project adopted a mixed methods approach to explore the experiences of women who gave birth in Switzerland. The first, quantitative part was an online survey on childbirth experience among over 6000 mothers in Switzerland that focused on informal coercion [2] . According to the Swiss Academy of Medical Sciences, medical measures are considered coercive if they are carried out against a patient's will or despite their opposition or resistance, which highlights the importance of patient autonomy in healthcare [29] . Formal coercion is a legally justified restriction of a patient's autonomy when they lack power of judgment; involuntary committal or compulsory drug treatment for instance are customary measures in psychiatric settings in Switzerland. Seeing as women in labour generally possess power of judgment, less evident or so-called informal methods of coercion may be more likely in maternity care. Informal coercion ranges from relatively covert or subtle forms such as denying women the time or information necessary to reach an autonomous decision to more blatantly coaxing them into complying by means of pressure, intimidation or manipulation or even performing procedures without their consent or despite their resistance [2, 29] . More than a quarter (26.7%) of the women who participated in the survey reported that they had experienced informal coercion during birth [2] . In line with previous research outlined above, experiencing informal coercion was detrimental to women's birth experience and their mental health: Women who were subjected to informal coercion were less satisfied with their childbirth and were more at risk of post-partum mental health issues. Moreover, migrant women reported higher rates of informal coercion than Swiss women and were more likely to experience post-partum mental health issues. This article presents the findings from the second, qualitative part of the project, which aimed to expand on the results from the first part and thereby contribute to a better understanding of informal coercion specifically and mistreatment more generally by exploring women's individual experiences of mistreatment, the aspects of the experience that most affected them during and after birth as well as . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint how they attempted to cope with it. To this end, we first analysed the nearly 8000 comments women left in the online survey and subsequently conducted and analysed interviews with 11 women who reported a negative birth experience. The present research project used a mixed methods approach to assess the prevalence and women's experience of informal coercion specifically and mistreatment more generally during childbirth in Switzerland. The first, quantitative part was a nationwide, cross-sectional online survey on women's childbirth experience [2] . The survey encompassed questions about their pregnancy and birth in general and focused on informal coercion and the informed consent process regarding any obstetric interventions they underwent specifically. At the end of every section, participants were given the opportunity to provide additional information concerning the previous questions in open-ended text boxes. Due to the vast number as well as the rich content of these comments, it was decided that they should be coded and analysed and included in the second, qualitative part of the project. The key component of this second part was an interview study with women who reported a negative experience during childbirth and aimed to expand on the findings from the survey in order to better understand coercion and mistreatment as well as how the women's experiences affected them during and after birth. One of the authors (StM) constructed the semi-structured interview guide according to the guidelines by Helfferich [30] . Although the main focus of the interviews was informal coercion, it also incorporated questions based on Bohren et al.'s typology of mistreatment during childbirth as well as research on treatment pressure in psychiatric settings [31, 32] . The same author adapted the first draft of the interview guide to feedback provided by the co-authors and subsequently translated it from German to English and French (see S1 Table for English interview guide). The four principal questions addressed women's overall birth experience, interactions with HCP, decision-making during childbirth and cognitive processing of the birth. At the end, the interviewees were asked a range of demographic questions. Although mistreatment can occur during all stages of pregnancy, labour, birth and the postpartum period, the present study focused the period between the women's arrival at the birthing facility and the first few hours after birth. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint Out of the 6054 women who completed the survey and met the eligibility criteria, more than half (n = 3547) wrote at least one comment in answer to a question potentially relevant to mistreatment, that is, which concerned a specific medical intervention they underwent or informal coercion and the informed consent process in general; the total number of comments was 7753. This constituted the sub-sample and data set for the qualitative analysis of the survey comments. In order to recruit participants for the interview study, e-mails were sent out to all the survey participants who had provided their e-mail address for updates on the study (n = 233), inquiring whether they were interested in participating in an interview study on childbirth experience. This e-mail contained a brief and vague description of the goal of the study -i.e., to discover more about women's individual birth experiences -and a few screening questions, the most important of which was a request to describe their childbirth and any negative experiences they may have had in a few words. Furthermore, we posted a call for participation on our website and sent the same screening questions to the women who answered it. Out of the 50 women who were willing to participate, 11 were chosen for an interview. The inclusion criteria were that they described a negative interaction with HCP during birth, that they had given birth in a facility in Switzerland and that their child was no more than two years old. The women's age ranged between 29 and 40 years (M = 34.8), their children's between three and 20 months (M = 12.3). Seven women were Swiss, two were from neighbouring states (Germany, France) and two were from non-neighbouring states (Poland, Brazil). All women gave birth at a hospital; two by spontaneous vaginal delivery, four by caesarean section and five by vacuum delivery. Regarding their main caregivers during birth, five were primarily treated by doctors and midwives, five by midwives and one by doctors. Eight women were primiparous and three had given birth before. Most women in the sample were highly educated: Eight women had a university degree, one had completed higher technical and vocational training and two had completed basic vocational training. All women apart from one had also participated in the online survey. The survey data was collected between August 2019 and January 2020 using the Qualtrics online survey software [33] and subsequently processed in Excel. The interviews took place between May and November 2020. Due to the COVID-19 pandemic, it was not possible to conduct the interviews face-to-face. Instead, they were carried using the video conferencing service BlueJeans [34]. The first author (StM) conducted all the interviews; eight in Swiss German, two in English and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint one in French. Most interviews took roughly half an hour (range: 25 -77 minutes). Following each interview, the main contents and possible minor adjustments to the interview guide were discussed with another author (SO). The interviews were recorded and subsequently transcribed by one researcher (StM) using the software f4transkript [35] . Information that could allow the direct identification of the interviewees such as their own name or the names of partners, children, HCP, hospitals or places was removed from the transcripts. The interview transcripts were then imported into the ATLAS.ti 8 software for the thematic analysis [36]. One of the authors (StM) translated German and French verbatim quotes into English for the purpose of this publication. Because this was a national study, all seven regional ethics committees in Switzerland confirmed that by the Swiss Human Research Act, the current study did not require ethical approval (Req-2019-00116). The survey participants were asked to confirm that they had understood the study information and to provide their consent on the first page. The interview participants were asked to read the written consent form shown through screen sharing and to provide initial verbal consent before the start of the interview. Following the interview, they received the form by e-mail, which they were asked to sign and return. All data were anonymised and treated confidentially. Both data sets -i.e., the survey comments and the interview transcripts -were analysed using thematic analysis [37] . In a first step, one of the authors (StM) coded all 7753 survey comments inductively and discussed ambiguous comments, code definitions and examples with another author (SO). As a means of validation and measure of inter-rater agreement, a midwife research intern independently coded one third of the comments. After coding the comments in 1669 survey responses, she received feedback and the codes and definitions were discussed. The inter-rater reliability was calculated based on a validation sample of 533 survey responses. The overall agreement differentiating between women who experienced any form of mistreatment and women who did not was good (Krippendorf's alpha = .74, 95% bootstrap confidence interval [.66;.82]), although the reliability of the individual codes varied considerably (S2 Table) [38] . The code list generated based on the survey comments was not consulted again until the final stage of the qualitative analysis of both data sets to ensure independent, inductive coding and the creation of new codes throughout the interview analysis process. In the second part of the qualitative analysis, each interview transcript was . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint first individually coded and then discussed in a group of three to four researchers (StM, SO and one to two midwives per interview). The midwives received only the two to three interviews they were asked to code. They had no insight into the other interviews or the code list based on the previously discussed interviews. Analysis sessions were held for every interview, where the individual codes were examined, compared and discussed and the code list was adapted accordingly. After the final interview analysis session, the two code lists generated during the survey and the interview analysis were compared to each other and to the typology of mistreatment by Bohren et al. Specifically, the typology of mistreatment was used to structure the data and to assign the codes that matched it to the according themes and sub-themes. The two code lists based on the survey comments and the interviews largely overlapped and many of the codes that referred to mistreatment matched the typology by Bohren et al., even if the exact term often differed (an overview of all themes and codes can be found in S3 Table) . Although the original research question focused on informal coercion, the women described a wide range of negative experiences that encompassed not only coercion, but also disrespectful, abusive and physically and verbally violent treatment covered in Bohren et al.'s typology of mistreatment. We found instances of all types of mistreatment according to the typology in the survey comments and the interviews except for stigma and discrimination, which none of the survey comments in question referenced explicitly enough to justify coding it and was not described in any of the interviews. Physical and/or sexual abuse was only coded in the survey comments since it did not appear in any of the interviews. Seeing as none of the women reported breaches of confidentiality, the according theme was shortened to "lack of informed consent" for the purpose of this paper. In addition to the different types of mistreatment, the inductive coding of the interviews allowed the identification of a further five themes, including informal coercion and factors that often co-occurred with mistreatment. The results are divided into two sections: First, the types of mistreatment we identified and their frequencies in the survey comments will be presented and subsequently the five themes that emerged in the interviews will be described and illustrated with quotes. Table 3 shows the six out of the seven types of mistreatment and the sub-types according to the typology by Bohren et al. that were found in the survey comments and the interviews, as well as . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint their frequencies in the survey comments. Most comments referred to various types of mistreatment and therefore received multiple codes, which explains why the percentages in Table 3 add up to over 100. Out of the 3547 survey participants who wrote at least one comment in answer to a question relevant to mistreatment, 992 (28.0%) described at least one type of mistreatment. Loss of autonomy 103 2.9 Health system conditions and constraints 11 0.3 1 Percentage out of all women who wrote a comment relevant to mistreatment. 2 Physical and sexual abuse were taken together due to their small number as well as a high degree of overlap or unclear distinction between the two. We identified five themes in the interviews: informal coercion, risk factors for mistreatment, consequences of mistreatment, examples of good care and what's needed to improve maternity care. These five themes and their respective sub-themes are described and illustrated with quotes below. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint Informal coercion was mainly characterised by a lack of respect for women and their autonomy, which undermined the informed consent process. The women were often either denied the time and/or information necessary to make an informed choice or not included in decision-making at all. Many of the women described how HCP pressured them to comply, for instance by insisting on an intervention. One woman for example was given morphine during labour despite her repeated opposition. Furthermore, many recounted that they were not taken seriously as individuals, but rather that their wishes, needs, sensations and judgment were dismissed and interventions were carried out despite their concerns. One woman for instance reported that the HCP ignored her when she repeatedly told them the anaesthesia was not effective and proceeded with the caesarean section regardless. A number of factors seemed to facilitate mistreatment. Several women talked about how they were not able to think, not able to cope or how they felt insecure or helpless during birth, which left them unable to defend themselves. This in turn often led to procedures being carried out without the women's consent. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. The women reported a wide range of consequences following their experience of mistreatment, which were further divided into four sub-themes: immediate reactions, birth experience, after-effects and coping. Immediate reactions. Women's immediate reaction to mistreatment depended on their assertiveness and their understanding of the patient-caregiver relationship. More assertive and confident women stood up for themselves by opposing HCP when they felt that their autonomy was not being respected. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. Less assertive women or women who seemed to adhere to a more traditional understanding of the roles of patients and caregivers on the other hand often submitted themselves to the HCP. That is, they did not question the HCP's opinions, gave in to pressure or did not dare to resist. This often coincided with self-doubt and self-deprecation. And we felt like, really like part of a production system, you know. We felt in a rush, like everything has to be in a rush, and it's ta ta ta ta ta, and we really felt extremely bad with this, it was terrible for us. (Interview 5) One woman recounted how she felt robbed of a positive birth experience due to the various types of mistreatment she suffered at the hands of her main caregiver. After-effects. Most women who reported being mistreated struggled with coming to terms with their experience and felt sad or frustrated following their birth. These feelings often persisted for a long . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. Many also struggled with regrets or blamed themselves for what they experienced. Some women described how their experience of mistreatment affected or changed their feelings, attitudes or intentions regarding a potential future pregnancy and birth. Coping. The women often pointed out how it took time for them come to terms with or let go of what happened to them. In terms of processing their experience, most women found talking about their birth helpful and important, be it with the HCP who were involved, with other (mental) health providers or with their family and friends. Some women also compared themselves to others whose experience they judged as worse than their own or focused on positive aspects of their birth or on the fact that their baby was born healthy. Some women also recounted positive experiences and interactions with HCP during childbirth, such as HCP treating them with empathy, communicating openly, respecting boundaries and patient autonomy as well as enabling or even encouraging them to make their own informed decision. Examples of good care also included HCP giving women time to come to terms with a decision even after it had essentially been made. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. The last theme encompasses women's own wishes and suggestions for improving maternity care; both what they would have wanted during their own childbirth as well as general improvement suggestions. Almost all women stressed the need for HCP to treat them with respect and empathy, to provide more support and help and to take more time for them. Several women indicated that they did not understand the interventions they underwent or the reasons for them and that they would have required more orientation. Some also recounted that they felt rushed and wished for more time to consider and process information. The interviews made it clear that women's relationship with the HCP was a key aspect of their birth experience, seeing as they emphasised the need for a main caregiver they knew they could trust and supported them. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. The present study aimed to expand on the results from a nationwide survey on childbirth experience and thereby contribute to a better understanding of mistreatment during childbirth and how it affects women during and after birth. To this end, we analysed the comments collected in the survey and the interviews that were conducted with women who reported a negative experience during childbirth. Our findings indicate that women are subjected to various types of mistreatment during childbirth in Switzerland, which has a negative impact on their birth experience and their well-being. In addition to mistreatment, we identified informal coercion as a specific type of mistreatment, risk factors for and consequences of mistreatment, examples of good care and women's perspectives on what is needed to improve maternity care in the interviews. The quantitative analysis of the survey comments showed that the number of women who described mistreatment in a comment -i.e., 28.0% of all women who wrote a comment -matched the 26.7% of women who reported informal coercion in the previously published quantitative part of the project [2] . Although the initial research question focused on informal coercion, women described various types of mistreatment according to Bohren et al.'s typology. The two most common types of mistreatment found in the survey comments were ineffective communication, which was coded in 17.4% of the comments, and lack of informed consent, which 15.1% of the comments referred to. These were also two of the three most reported types of mistreatment in van der Pijl et al.'s study in the Netherlands [5] . It seems many women do not receive sufficient information or orientation during childbirth and are not respected as individuals, which leaves them feeling insecure or passive and undermines the informed consent process. An interesting finding was the difference in language used to describe experiences of mistreatment between the survey comments and the interviews. While the survey participants used more explicit and more negative words to describe their experience, the interviewees were more cautious and chose less explicit words. It may be easier to report such an intimate and distressing experience anonymously in an online survey than to describe it in an interview, which underscores the importance of combining the two approaches. A study with . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint postpartum women showed that they disclosed significantly more sensitive information such as intimate partner violence when they were guaranteed anonymity compared to confidentiality of their responses [39] . The fact that many of the survey participants and all interviewees described several types of mistreatment suggests that mistreatment is rarely a single, isolated event, but rather that certain types of mistreatment frequently co-occur or may even give rise to others. For example, failure to respect a woman's autonomy and to communicate effectively undermines the informed consent process, which in turn can result in procedures being carried out against her will. The overlap and relationship between different types of mistreatment is an avenue worth exploring in future research. In addition to mistreatment, a further five themes emerged through in the interviews: informal coercion, potential risk factors for mistreatment, consequences of mistreatment, examples of good care and what's needed to improve maternity care. These themes can precede, co-occur with or follow mistreatment and thus provide a fuller picture and a broader understanding of the phenomenon. Informal coercion was identified as a central theme in the interviews and was characterised by a lack of respect for women's autonomy. This finding highlights the importance of enabling and encouraging women to actively participate in decisions regarding their care. This can be achieved through shared decision-making (SDM), which promotes open, honest and respectful communication and involves patients and HCP collaborating to make health care decisions that are based upon the best available evidence and patients' preferences, values and needs [40] . SDM is therefore argued to be "the pinnacle of patient-centred care" [41] . In order for HCP to put SDM into practice however, they must subscribe to the guiding ethical principle that individual self-determination is a desirable goal and support patients to achieve this goal [42] . Although SDM is beneficial to patients, HCP and health care facilities and systems alike, a number of barriers still prevent it from being the norm in maternity care, which include "existing cultural norms of 'the doctor knows best' and 'patient acquiescence'" [43] . Begley, Daly, Panda and Begley argue that other factors such as concerns over litigation, private insurance that pays more to the obstetrician if more interventions are carried out, constraining guidelines and management policies, HCP's level of confidence and skills and HCP making decisions based on their personal convenience are most likely additional barriers in the way of SDM [43] . Therefore, structural and systemic change is needed to foster acceptance of a culture of SDM and thereby implement it as the norm in maternity care. A number of factors were discerned that often occurred in the context of mistreatment and therefore may contribute to, facilitate or exacerbate it. These risk factors pertained to the woman (e.g., . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint "not being able to think"), to interactions with the HCP or her partner (e.g., the power imbalance between HCP and patients) or to the situation (e.g., prolonged labour). While this finding is consistent with studies that have demonstrated effects of socio-demographic factors such as nationality or race on mistreatment, the present study does not allow any causal interpretations and future research should investigate the link between these potential risk factors and mistreatment [2, 6] . Many of the women reported negative consequences of mistreatment that affected them both in the short and/or long term. This was the case for both comparably mild and more severe experiences of mistreatment. This finding corresponds with van der Pijl et al.'s findings, who identified a theme by the same name in their inductive analysis, which most often referred to emotional consequences that tormented some women even years later [5] . In the present study, more assertive women reacted to mistreatment with resistance and defended their autonomy during childbirth, while less assertive women or women who seemed to have a more traditional understanding of the patientcaregiver relationship submitted themselves to the HCP. This finding emphasises the need to respect women's autonomy and to pay particular attention when treating less assertive or primiparous women. Experiencing mistreatment resulted in a negative appraisal of the whole birth experience or parts of it. This ties in with previous studies that found negative effects of mistreatment on women's satisfaction with childbirth [2, 4] . For some women, mistreatment resulted in a change in attitudes or intentions regarding (future) childbirth. In line with the previously referenced Italian study, certain women decided not to return to the same facility if they became pregnant again or even not to have any more children [3] . Many dealt with after-effects such as feelings of sadness and frustration, guilt and regret, selfblame, flashbacks, obsessing over "what if" scenarios and how their experience could have been different or avoiding memories of their birth. Byrne, Egan, Mac Neela and Sarma, who explored the subjective experience of birth trauma, found that coping through detachment, which encompasses avoidance and dissociation, was a common response to a traumatic birth experience [44] . While the present study did not assess mental health indicators, the previously described after-effects are established symptoms of PTSD. Furthermore, some women reported they had been diagnosed with PPD and/or that they were currently receiving psychological treatment to come to terms with their birth. These results tie in with previous research that has confirmed a link between a negative or traumatic birth experience and post-partum mental health issues [13] [14] [15] [16] [17] [18] [19] . The women described different ways of coping with their experience of mistreatment, such as discussing it with other people or extenuating it. Asked about what they found most helpful in . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Although there is limited evidence for the effectiveness of debriefing interventions in preventing postpartum mental health issues, several reviews nonetheless support our finding that women generally find talking about their experience and being listened to beneficial [45] [46] [47] . One of the most frequently used codes was extenuation, seeing as all women diminished or excused their mistreatment. This ties in with Ayers, who found that women who self-reported a traumatic birth, regardless of whether they had PTSD symptoms or not, engaged in various thought processes to help cognitively process their experience such as retrospectively taking a fatalistic view of birth or focusing on the inevitability of labour [48] . Our findings concerning the consequences of and women's coping with mistreatment during childbirth give evidence to the serious and long-lasting impact it can have on women's well-being and to the benefits of sharing their experience. Furthermore, they indicate the need for sensitive after-care for all mothers to support them in processing their birth and ideally detect and treat postpartum mental health issues. [49] . RMC refers to "care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth" and is recommended by the WHO [50] . So far, research on the effectiveness of such policies is sparse. A systematic review of five studies undertaken in four African countries found moderate evidence that multi-component RMC policies reduced women's experiences of disrespect and abuse overall [51] . However, there was less evidence for an effect on individual types of mistreatment. Moreover, the most successful elements as well as the sustainability of such policies remain unclear. The fact that some women in our study experienced elements of both mistreatment and respectful care confirms . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint that the two do not necessarily exclude each other and that RMC is more complex than the mere absence of mistreatment [21, 52] . This in turn suggests that preventing mistreatment and implementing RMC may require simultaneous yet different types of interventions [21, 52] . Therefore, researchers and health care providers alike must strive to prevent mistreatment as well as implement RMC in order to ensure respectful and dignified care for all -before, during and after childbirth. This corresponds with our finding that most women stressed the need for more sensitive care and for HCP to treat them as individuals, which was particularly well illustrated in a quote by one interviewee who emphasised the importance of HCP acknowledging birth as an exceptional situation and experience and taking time for women despite time constraints. Therefore, in order to truly attain high quality women-centred maternity care, it is essential to listen to women individually and collectively and to incorporate their insights into healthcare policies and guidelines. Taken together, our findings highlight how multifaceted and multi-layered mistreatment during childbirth is. While the interpersonal level of the caregiver-patient relationship may be the most obvious and interventions directed at HCP are essential, the systemic and structural level must not be ignored. However, while systemic factors can provide contextual explanations for mistreatment, they can never serve as justifications. One of the primary strengths of the study is its design, which integrated two different data sets: the comments written in a largescale, nationwide online survey on childbirth experience and the interviews conducted with women who reported being mistreated during childbirth. This allowed both quantitative conclusions regarding the frequency of different types of mistreatment as well as qualitative conclusions concerning women's individual experiences of mistreatment and how these affect them during and after childbirth. Furthermore, the qualitative analysis combined inductive with theory-guided thematic analysis. On the one hand, this approach confirmed the applicability of Bohren . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint et al.'s typology of mistreatment in a Swiss context. On the other, it allowed a further five themes to be identified that contribute to a fuller picture and a broader understanding of the phenomenon. The limitations of this study include the self-selection of participants, both for the survey and for the interviews. In the survey, women could choose to provide further information about their birth in open-ended text boxes at the end of every section, however, this was not mandatory. As for the interviews, the previously referenced tendency to disclose more sensitive information in an anonymous setting may also have played into the relatively low response rate of 21% to the recruitment e-mail, especially considering that the women it was sent to had all already filled in the questionnaire [39] . Women who chose to participate in the interview study are likely to differ from women who did not. For instance, women who had a particularly traumatic experience and are coping through detachment may shy away from sharing their story in an interview. Another important limitation of the study is the lack of diversity in the interview sample, considering that all interviewees were white heterosexual cisgender women who were Swiss nationals or residents and mostly highly educated. Future research should include marginalised populations such as the LGBTIQ+ community and refugees and asylum-seekers. Seeing as marginalised groups are more vulnerable to stigma and discrimination in general, they are also likely to be more at risk of mistreatment in maternity care [6, 54] . The previously referenced US study for instance found that Black, indigenous and women of colour experienced significantly higher rates of mistreatment [6] . Furthermore, the sample only included women living in the German speaking part of Switzerland, since no one from the French speaking part met the eligibility criteria and no one from the Italian speaking part replied to the recruitment e-mail. Lastly, it seems important to point out that the interviews took place during the COVID-19 pandemic. The effects of this context in itself and the fact that the interviews took place by video call as a consequence are unclear. Although many aspects of our life have shifted to the digital sphere and we have become accustomed to life online over the course of the pandemic, some important aspects that are inherent to face-to-face interactions such as nonverbal signals and body language cannot be conveyed in a video call. Furthermore, meeting in person provides the opportunity for building trust through small talk prior to an interview. It is therefore possible that face-to-face interviews would have encouraged women to share more intimate details. Despite these limitations, the study shows that mistreatment is a reality in Swiss maternity care and affects women both during and after birth and introduces avenues worthy of further investigation. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 8, 2021. ; https://doi.org/10.1101/2021.06.07.21258295 doi: medRxiv preprint Research has shown that mistreatment during childbirth is an issue of global magnitude, which was acknowledged by both the WHO and the UN. The results from the present project confirm and extend previous findings by demonstrating that women in Switzerland face various types of mistreatment during childbirth. Furthermore, this study sheds light on women's individual experiences of mistreatment and how these affect them during and after childbirth. It pinpoints informal coercion as a specific type of mistreatment, identifies risk factors for and consequences of mistreatment as well as examples of good care and amplifies women's views on what is needed to improve maternity care. The findings from this study thus contribute to a better understanding of mistreatment during childbirth and highlight the need for systemic efforts to increase HCP's awareness of the issue and to enable and empower women to actively participate in decision-making in order to achieve respectful, dignified and high-quality maternity care for all. Obstetric violence: a Latin American legal response to mistreatment during childbirth Informal coercion during childbirth: risk factors and prevalence estimates from a nationwide survey of women in Switzerland Abuse and disrespect in childbirth assistance in Italy: A community-based survey Obstetric violence in Spain (part I): Women's perception and interterritorial differences PubMed PMID: 32396552; PubMed Central PMCID: PMCPMC7217465 provide funding to carry out this study. Two authors (TL and RV) affiliated with these organizations were part of the research team representing the client. TL is a member of Geboortebeweging, a clinical psychologist and a PhD student (GGzE & Vrije Universiteit). RV is also a member of Geboortebeweging and is a certified babywearing consultant and bonding coach (Hechte Band). Both authors were involved in managing the #GG campaign in 2016, in which they also participated themselves. TL and RV were involved in the research process from the start. 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What Women Want: Demands for Quality Reproductive and Maternal Healthcare from Women and Girls Reproducing while Black: The crisis of Black maternal health, obstetric racism and assisted reproductive technology First and foremost, we are incredibly grateful to the women who took the time to share their birth experience with us. We would like to thank Lea Bucher, Anja Hurni, Raquel Mühlheim, Cecilia Gebhart and Rahel Messmer for their valuable contribution to the analysis of the interviews. Conceptualisation and design: all authors.