Disrespect and abuse during childbirth and postpartum depression: a scoping review

This study aims to map, within the scientific literature, the relationship between disrespect and abuse during childbirth and the occurrence of postpartum depression. This is a scoping review designed in accordance with the recommendations of the Joanna Briggs Institute. The search was performed in Embase, LILACS, MEDLINE, PsycINFO, Web of Science, and in the CAPES Portal of Theses and Dissertations. We included studies that investigated the relationship between disrespect and abuse during childbirth with postpartum depression, considering cases diagnosed by physicians and by self-reports via validated scales, without restrictions regarding the year of publication and language. A total of 3,399 publications were identified and, after removing the duplicates and reading the title, abstracts, and the full-texts, seven articles were selected to integrate this review. Studies were published from 2017 onward, in four countries. Women who had experienced disrespect and abuse during childbirth were more likely to experience symptoms of postpartum depression. A standard terminology is necessary for disrespectful and abusive care during childbirth, as well as the elaboration of a measurement instrument that is universally accepted.


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 1,2,3,4 .There is no consensus on the terminology used 4 and, therefore, this article will use the term disrespect and abuse due to its frequent use in the international literature 3,5,6,7,8,9,10 .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 11 .
Although a serious violation of human rights, disrespect and abuse during childbirth affects many women in health institutions worldwide 12 .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 13 .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% 5 .In Brazil, a national hospital-based survey of 23,940 women 14 , 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) 6 , 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 7 , reduced trust in health units 8 and less involvement of women with maternal and neonatal health care 9 .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 9,10,15 .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 15,16,17 .
Postpartum depression is a form of depressive disorder that occurs in the first year after childbirth 18,19 , affecting 17.2% of women worldwide 20 .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 21,22 .The most common symptoms include depressed mood, sleep disturbances, loss of energy, feelings of guilt, irritability, anxiety, and suicidal ideations 23 .Moreover, postpartum depression can negatively interfere in the interaction between mother and baby 24 , favor the early interruption of breastfeeding 25 , cause growth problems 26 , and contribute to cognitive/behavioral changes in children whose mothers presented symptoms of postpartum depression 27,28 .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 29 .The checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) 30 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) 31 , 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

Box 1
Search strategies in databases and grey literature.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 crosssectional, 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 32,33,34,35,36,37,38 .All studies evaluated postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) 32,33,34,35,36,37,38 , and one of them used the short version of the scale, the EPDS-6 32 .In addition to the EPDS, one study also applied the Mini International Neuropsychiatric Interview (MINI) 37 (Box 3).
Regarding the types of disrespect and abuse during childbirth reported by the women, we identified the lack of a companion during childbirth 36 , 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 36 .Verbal 38 and/or physical abuse, refusal of care, and unwanted procedures during childbirth were also reported 33,35,37 .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 34 (Box 3).
All studies showed that disrespect and abuse during childbirth was associated with a higher occurrence of postpartum depression symptoms 32,33,34,35,36,37,38 .One study demonstrated that abuse and lack of a companion during childbirth were significantly associated with a higher risk of postpartum depression 37 .In another investigation, women who suffered psycho-affective or verbal obstetric violence were more prone to postpartum depression 35 .
Symptoms of postpartum depression were higher in women submitted to more forms of disrespect and abuse during childbirth 38 .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 33 .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 32 .In turn, disrespect and abuse during childbirth was associated with postpartum depression in both the public and private health sectors 34 (Box 3).

Figure 1
Flow diagram on the process of selecting studies for scoping review.CAPES: Brazilian Coordination for the Improvement of Higher Education Personnel.

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) 32,33,34,35,36,37,38 .These forms of disrespect and abuse during childbirth have also been identified in other studies 39,40,41 .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 42 .

Box 2
Description of the studies included in the scoping review according to authors/year, location, type of study, objectives, and population/sample size.The studies included in this review evaluated disrespectful and abusive childbirth care using different instruments 32,33,34,35,36,37,38 .In 2014, the WHO published a document recommending the development of research to measure disrespect and abuse during childbirth 12 .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 1,7,41,43,44,45,46 .Nevertheless, even one of the most popular instruments, proposed by Bohren et al. 45 , 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 4 .

STUDY
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 4 .Some of the other nomenclatures

Box 3
Instrument for evaluation of disrespect and abuse during childbirth, instrument for evaluation of postpartum depression, types of self-reported disrespect and abuse during childbirth, and main results.

SELF-REPORTED DISRESPECT AND ABUSE DURING CHILDBIRTH TYPES MAIN RESULTS
Box 3 (continued) 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 2,3,4,47 .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 4,48 .
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 32,33 .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 41,43,48,49 , and there are few studies that analyze its consequences 4 .However, corroborating the association identified in this review, a cross-sectional study conducted in Southern Brazil 50 , 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 16 , contributing to the occurrence of psychological suffering such as postpartum depression 51 .
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 52 .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 20,53 .
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.