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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 212-218

Assessment of birth satisfaction among the women attending the immunization clinics in South Delhi: A cross-sectional study

Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission15-Oct-2018
Date of Decision13-Nov-2018
Date of Acceptance29-Nov-2018
Date of Web Publication25-Jan-2021

Correspondence Address:
P Aravind Gandhi
Room No. 517, Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_142_18

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Background: A woman's satisfaction with childbirth services can have a significant impact on her mental health and ability to bond with her neonate. Indian women's satisfaction with childbirth services has been explored qualitatively, or by using nonstandard local questionnaires, but quantitative data gathered with standardized questionnaires are extremely limited Objective: The aim of this study is to assess the birth satisfaction level among women of South Delhi with institutional normal vaginal delivery and to determine the factors associated with it. Materials and Methods: A cross-sectional study was conducted among the 102 mothers attending the immunization clinics of a primary care and a tertiary care center in South Delhi during March 2018–April 2018. A prevalidated, semi-structured, Hindi version 36-item Scale, with 10 domains, Scale for Measuring Maternal Satisfaction in normal birth was used. Statistical Analysis: Pearson Chi-square, Mann–Whitney test, and Fisher's exact test were applied as tests of significance. Results: The median age in completed years of the respondents was 24 years (interquartile range = 5). Majority, 58 (61.1%), of the participants, were more satisfied. Bribes were asked from 61.1% of the mothers. Demanding bribes, perceived competence of healthcare providers by the mothers, and the motivation given by others were significantly associated with the individual domains of birth satisfaction such as postpartum care satisfaction and overall support received. No significant association between the sociodemographic, birth time events and overall birth satisfaction levels was obtained. Conclusion: About 38.9% less satisfied mothers and the domain-specific associated factors give the scope for the areas to be worked on to improve the quality of maternal and patient-centric services. Hospitals should publicly declare and implement zero tolerance for bribes in the care of mothers.

Keywords: Birth satisfaction, Delhi, Indian women, institutional delivery, normal vaginal delivery

How to cite this article:
Gandhi P A, Doley P, Balasubramanian T, Mishra A, Pardeshi G. Assessment of birth satisfaction among the women attending the immunization clinics in South Delhi: A cross-sectional study. CHRISMED J Health Res 2020;7:212-8

How to cite this URL:
Gandhi P A, Doley P, Balasubramanian T, Mishra A, Pardeshi G. Assessment of birth satisfaction among the women attending the immunization clinics in South Delhi: A cross-sectional study. CHRISMED J Health Res [serial online] 2020 [cited 2022 Aug 13];7:212-8. Available from: https://www.cjhr.org/text.asp?2020/7/3/212/307818

  Introduction Top

Childbirth, although a physiological process, has been associated with multiple risks and stress on the women, even before the time of conception till postpartum, in India. Ensuring universal access to safe, acceptable, good quality sexual and reproductive health care, particularly contraceptive access and maternal health care, can dramatically reduce global rates of maternal morbidity and mortality.[1]

Every woman around the world has a right to receive respectful maternity care. The concept of “respectful maternity care” has evolved and expanded over the past few decades to include diverse perspectives and frameworks.[2] In 2014, the WHO released a statement calling for the prevention and elimination of disrespect and abuse during childbirth, stating that “every woman has the right to the highest attainable standard of health, including the right to dignified, respectful care during pregnancy and childbirth” and stressed to include respectful care as an essential component of quality care.[1]

A woman's satisfaction with childbirth services can have a significant impact on her mental health and ability to bond with her neonate. The intrapartum period is more the period where women are most vulnerable for abuse and disrespect, which is human right issue.[1] The term “birth satisfaction” represents the survival of the woman and delivery of a healthy infant and also the provision of choice and control to childbearing women.[3] It should be mentioned that the experience of women in labor may also influence maternal and neonatal outcomes since anxiety during labor is associated with high adrenaline levels, abnormal fetal heart rate, decrease of uterine contractility, an increase in the duration of the active labor stage, and low Apgar scores.[4] On the other hand, the emotional support, guidance, and comfort measures may reduce anxiety, fear, and therefore, their adverse effects.[4]

Birth satisfaction and respectful maternal care have direct impact on the percentage of institutional deliveries. Hence, this acquires higher relevance in the Indian scenario because institutional birth in our country is only 78%, and 38% of the women do not receive any postnatal care within 2 days and thus contributing to poor maternal mortality ratio (MMR) of 130 in India.[5],[6]

The National Health Policy of India released in 2017 promises providing health care with dignity to its subjects, which is in line with the WHO' stand on childbirth care and ensuring a women-friendly environment in the public-health facility.[1],[7]

Knowing postnatal women's opinions and satisfaction with services makes the services more women-friendly and women-oriented. Indian women's satisfaction with childbirth services has been explored qualitatively, or by using nonstandard local questionnaires, but scientific data gathered with standardized questionnaires are extremely limited.[8] Particularly in Delhi, we could not find any quantitative assessment of birth satisfaction with validated questionnaires. Hence, in the present study we have focused on assessing the birth satisfaction level among the women of South Delhi with institutional normal delivery, quantitatively, and analyzing the factors associated with the levels of birth satisfaction.

  Materials and Methods Top

A cross-sectional study was conducted among the mothers attending the immunization clinics of a Primary Care Maternal and Child Welfare center and a tertiary care hospital in South Delhi during March 2018–April 2018. A sample size of 86 was calculated, by taking the prevalence of birth satisfaction to be 68.7% from Jha et al. study,[8] absolute error of 10%. Considering the nonresponse rate as 20%, the final sample size was calculated as 102.

Inclusion criteria

Mothers who had a normal vaginal delivery in an institution and attending the above immunization clinics for the 1st, 2nd, and 3rd Pentavalent/Oral Polio Vaccine/Injectable Polio Vaccine dose were included in the study.

Exclusion criteria

Mothers attending the immunization clinics with children aged more than 12 months, women who underwent cesarean section or developed complications after vaginal delivery and home-based delivery were excluded from the study.

Complete enumeration by consecutive sampling, according to the eligibility criteria, was done for 10 days, to meet the required sample size.

The variables studied were – religion, the area of residence, educational status, family type, primi status of parity, place of delivery, breastfeeding characteristics, and the presence of birth attendant.

A semi-structured, interviewer-administered Hindi (local language in Delhi) questionnaire which includes sociodemographic data and a validated scale for measuring maternal satisfaction – Scale for Measuring Maternal Satisfaction in normal birth (SMMS-normal birth) – was used.[8],[9] Six interviewers, who were the 6th-semester MBBS students, were oriented and trained for data collection, to ensure uniformity in eliciting the responses.

SMMS-normal birth consists of 36 items and 10 subscales, which measures 10 domains associated with childbirth satisfaction.[8],[9] Factors considered in the scale are as follows: perception of health professionals; nursing care in labor; comforting; information and involvement in decision-making; meeting baby; postpartum care; hospital room; hospital facilities; respect for privacy and meeting expectations. The cutoff score was calculated as 105.5 for SMMS-normal birth and the scores above cutoff value indicate more satisfied and below that indicates less satisfied with the childbirth care received.[8]

Permission was obtained from the authors of the SMMS scale and the validated Hindi version of SMMS scale, to use it in our study.

Data entry was done on Microsoft excel spreadsheet, which was cross-checked and analyzed using the statistical software SPSS version 21.0 (IBM Corp, Armonk, NY). Descriptive statistics (tables and pie charts) were used to present the data. Pearson Chi-square, Mann–Whitney test, and Fisher's exact test were applied to determine the significance between variables and the birth satisfaction. A value of P < 0.05 was considered to be statistically significant.

Approval was obtained from the Institutional Ethical Committee of Vardhman Mahavir Medical College and Safdarjung Hospital (S.No IEC/Sub/VMMC/SJH/Project/March/2018/5), before the start of the study. After explaining the details of the study to the participants in Hindi and assuring total confidentiality of their information, written informed consent was taken from each study participant.

  Results Top

The response rate was 93.1% (95 out of 102 forms were completed). The median age in completed years of the respondents was 24 years (95% confidence interval 24–25 years) (interquartile range [IQR] = 5 years).

Majority of the participants, 82 (86.3%) were in the age group of above 20 years and 90 (94.7%) were homemakers. Only 3 (3.2%) of the participating mothers reported as illiterates. The participants were almost equally distributed between nuclear 46 (48.4%) and joint 49 (51.6%) family, in numbers. Majority of the participants, 45 (47.4%), belonged to lower middle socioeconomic class, whereas 28 (29.4%) and 22 (23.2%) participants belonged to upper middle and upper lower class, respectively, according to Revised Kuppuswamy' scale [Table 1].
Table 1: Sociodemographic characteristics of the study participants (n=95)

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Most of the participants, 56 (58.9%) were primiparous, i.e., giving birth for the first time. Majority of the deliveries, i.e., 86 (91.5%) were conducted in the government institutes such as hospitals and dispensaries, whereas 8 (8.5%) of the deliveries were conducted in private hospitals. The deliveries were conducted by the doctors for the majority of the participants, i.e., 75 (79.8%) and the rest 19 (20.2%) were conducted by the nurses or auxiliary nurse midwives (ANMs). Birth attendants were allowed by the hospitals during the majority of the deliveries (57.9%). Among the participating women, 62 (65.3%) reported that they did not get any motivation for institutional delivery, from others such as ASHAs, ANMs, or family members. The time of initiation of breastfeeding was >30 min from delivery among the majority of the participants (83.2%), even though instructions regarding proper breastfeeding practices were provided to 57.9% of the study participants [Table 2].
Table 2: Distribution of the participants according to the birth characteristics of mothers

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Majority of the participants, 58 (61.1%), reported that bribes were asked by the hospital staff during and postdelivery [Table 2].

The Birth Satisfaction Scale scores derived for the participants were found to be nonnormally distributed (P = 0.008), by applying Shapiro–Wilk' test.

The median birth satisfaction score of the respondents was 123 (IQR = 42). Among the mothers who participated in the study, 58 (61.1%) were more satisfied with the services and experiences during the child-birth.

The scores of the 10 subdomains of the birth satisfaction scale were analyzed individually. All the 10 domains of the Birth Satisfaction Scale - Hospital facilities (P < 0.001), postpartum care (P = 0.002), information received and involvement in decision making (P = 0.001), meeting the baby (P = 0.001), intrapartum care (P = 0.007), overall support received (P = 0.001), expectations from institutional birth (P < 0.001), privacy (P < 0.001), compassion and respect (P < 0.001), experiences of having institutional birth (P < 0.001) were found to be not normally distributed, by Shapiro–Wilk test. Hence, median scores for each domain were calculated [Table 3].
Table 3: Median scores of subdomains of the birth satisfaction scale for the participants

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There was no significant association of birth satisfaction levels with any of the sociodemographic variables [Table 4] and birth characteristics [Table 5].
Table 4: Association of birth satisfaction levels with sociodemographic characteristics (n=95)

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Table 5: Association of birth satisfaction levels with birth characteristics (n=95)

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As the subdomain scores were not normally distributed, Mann–Whitney U-test was used to determine the association between the individual domain and the factors.

Mothers who were homemakers (median = 15) had significantly better scores than the employed mothers (median = 7) for the domain of “Information received and involvement in decision making” (U = 68, P = 0.009).

Multiparous women (median = 14) scored significantly higher than the primipara (median = 11) in the domain of “Expectations from institutional birth” (U = 701, P = 0.003).

Mothers from nuclear family (median = 14) scored better than the ones from joint family (median = 11) in the domain of “Expectations from institutional birth” (U = 802, P = 0.014). Mothers from joint family (median = 11) scored better than the ones from nuclear family (median = 9) in the domain of “meeting the baby (U = 816.5, P = 0.02).”

Mothers whose deliveries were conducted by nurses/ANMs (median = 16) had significantly lesser scores than the ones delivered by doctors (median = 19) in “postpartum care satisfaction (U = 499.5, P = 0.045).”

Mothers who had received motivation for an institutional delivery from others such as family, ASHAs, ANMs scored higher than the ones without such motivation in the domains of “Hospital facilities” (median 21 vs. 17; U = 723, P = 0.019), “Information received and involvement in decision-making” (median 16 vs. 13; U = 766.5, P = 0.044), “Intrapartum Care” (median 24 vs. 22; U = 768, P = 0.046), and “Overall support received (median 6 vs. 5; U = 746.5, P = 0.029).”

Participants who reported that bribes were demanded by the hospital staff (median = 5) scored less than that of the ones who were not asked to pay off bribes (median = 6) in the “Overall support received (U = 799, P = 0.034).”

  Discussion Top

In the present study, 61.1% of the mothers who had delivered in institutions, were more satisfied with their childbirth experience, which is similar to the satisfaction level of 68.7% reported by Jha et al.[8] at Chattishgarh, India. Studies from Ethiopia done by Bitew et al.[10] and Tayelgn et al.[11] revealed maternal satisfaction levels of 81.7% and 61.9%, respectively and Melese et al.[12] reported between 2.4% and 21%. Matejić et al.[13] in their study at Serbia reported a childbirth satisfaction level of 74.6%–82.2%. Christiaens and Bracke[14] in his cross-national study of the Netherlands and Belgium reported a high childbirth satisfaction (mean = 4.21; standard deviation = 0.53) among the women. Domingues et al.[15] reported a satisfaction level of 67%, the proportion of mothers who were completely satisfied with health-care ranges. A study by Mohammad et al.[16] from Jordan revealed that 75% of women were dissatisfied with the child-birth services. Studies conducted in Bangladesh and South Australia indicated that the level of maternal satisfaction on delivery care was 92.3% and 86.1%, respectively.[10] The difference in the satisfaction levels of our study from other studies may be explained by the difference in ethnicities, culture, and the different expectation levels among the mothers, especially in the western countries where it is high. The study tools used to assess the satisfaction levels were also different, which might have also contributed to the difference.

Since only mothers of live-births were included in our study, the “Halo effect” could have played a major role resulting in majority of mothers expressing higher levels of birth satisfaction, since delivering a live child was the primary objective.[15] Also considering a high MMR of 130/100,000 live births, achieving a healthy mother postdelivery could have masked other aspects surrounding the child-birth. This could have also stemmed from the lower expectation of women restricting herself to the physical health and well-being of the neonate and her body, since meeting these expectations is a significant factor associated with birth satisfaction.[17]

None of the sociodemographic variables and birth characteristics were associated with birth satisfaction level indicating that irrespective of these factors three-fifths of the women were more satisfied with their childbirth experiences. However, the present study revealed that 39% of the participants were less satisfied with their childbirth experiences; hence, the need to address their concerns still remains.

Maternal age was not significantly associated with birth satisfaction which is not in line with the findings of Jafari et al.[18] However, Jha et al.,[8] Srivastava et al.,[19] who reported that birth satisfaction was positively associated with a higher age of mothers. Multiparous women scored significantly higher than primiparous women in the domain of expectations from the delivery, most probably as they already had a delivery experience and hence, their expectation levels might have been lesser than that of primipara, a finding similar to the studies from Nigeria and Srilanka.[19] However, parity had no bearing on the overall birth satisfaction levels in our study, similar to Jha et al.,[8] Jafari et al.[18] findings.

In the present study, the presence of birth attendant did not have a significant association with levels of birth satisfaction, which is in contrast to the findings brought out by Srivastava et al.[19] in their systematic review and a Brazilian study by Domingues et al.[15] where the presence of birth companions positively influenced birth satisfaction.

In the present study, there was a significant association between the person who conducted the delivery (Nurse/ANM vs. Doctor) and the postpartum care satisfaction but not associated with overall birth satisfaction. Srivastava et al.[19] revealed a positive association between the perceived competence of the service provider and birth satisfaction, in the studies reviewed by them. However, the designation of the provider elicited in our study is only an indirect measure of the competence of the care providers perceived by mothers.

Bribes were asked from 61.1% of our study participants. It adds to the out-of-pocket expenditure (OOPE). Sudhinaraset et al. in their study in Uttar Pradesh reported that 24.2% of the mothers were demanded bribes.[20] Issac et al. reported that bribes form the single major part in the OOPE incurred during delivery.[21] Bribes were to be paid for availing the services of ambulance during transit and to the staffs of the overcrowded hospitals so that a bed is allotted in the ante-natal and postnatal wards.[21],[22] Studies reported the denial of care by the staff for not paying bribes.[20],[23] Bribes and the ensuing high OOPE acts as an impeding factor against choosing institutional delivery.[22],[23],[24],[25] The mothers who were demanded bribes by the hospital staff reported significantly less satisfaction in the domain of overall support received in our study. This is similar to the findings of previous studies, wherein bribes affected maternal satisfaction.[19],[21]

In this study, we have quantified the birth satisfaction levels in Delhi using the validated tool. However, there is limited external validity as it was done in immunization clinics of two public health hospitals and cesarean deliveries were not included. In addition, recall bias cannot be ruled out as the women were interviewed weeks after the delivery.

  Conclusion Top

Although the overall satisfaction levels during parturition was not associated with any demographic or birth time events, demanding bribes, perceived competence of health-care providers by the mothers, and the motivation given by others were significantly associated with the individual domains of birth satisfaction such as postpartum care satisfaction, overall support received, information received and involvement in decision-making, hospital facilities, and intrapartum care. Hence, the motivation for institutional deliveries must be made sure by the ASHAs and ANMs at the health-care system level. Hospitals should publicly declare and implement zero tolerance for bribes in the care of mothers. They should ensure that the mothers and attendants are sensitized about the anti-bribe measures, with a proper channel for complaints and prompt action to control the menace of fleecing patients. Confidence building measures among the mothers over the competence of the paramedical staff to conduct the deliveries must be built, to increase the satisfaction levels. The above measures for improving the birth satisfaction levels will ultimately strengthen the patient-centered care envisaged in the National Health Policy of India.


We would like to thank the 6th semester MBBS students, Mr. Pathak MSW and Mrs. Anita, the Health Educator, who helped in the data collection. We express our sincere thanks to the Medical officer in-charge of Fatehpur beri and the Head of the Pediatric Department, Safdarjung hospital, who gave us necessary permission to conduct the study in the immunization clinics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Prevention and Elimination of Disrespect and Abuse During Childbirth [Press Release]. World Health Organization; 2014. Available from: http://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/. [Last accessed on 2018 Oct 02].  Back to cited text no. 1
Hodin S. Respectful Maternity Care: A Basic Human Right; 2017. Available from: https://www.mhtf.org/2017/04/11/respectful-maternity-care-a-basic-human-right/. [Last accessed on 2018 Oct 02].  Back to cited text no. 2
Hollins Martin CJ, Martin CR. A survey of women's birth experiences in Scotland using the Birth Satisfaction Scale (BSS). Eur J Pers Cent Healthc 2015;3:478.  Back to cited text no. 3
Devasenapathy N, George MS, Ghosh Jerath S, Singh A, Negandhi H, Alagh G, et al. Why women choose to give birth at home: A situational analysis from urban slums of Delhi. BMJ Open 2014;4:e004401.  Back to cited text no. 4
National Family Health Survey 2015-16, Indian Institute of Population Studies. Available from: http://www.rchiips.org/NFHS/pdf/NFHS4/India.pdf. [Last accessed on 2018 Oct 02].  Back to cited text no. 5
Maternal Mortality Ratio, India New Delhi: National Institution for Transforming India. Available from: http://www.niti.gov.in/content/maternal-mortality-ratio-mmr-100000-live-births. [Last accessed on 2018 Oct 02].  Back to cited text no. 6
National Health Policy.Ministry of Health & Family Welfare. New Delhi; 2017. Available from: http://www.cdsco.nic.in/writereaddata/National-Health-Policy.pdf. [Last accessed on 2018 Oct 02].  Back to cited text no. 7
Jha P, Larsson M, Christensson K, Skoog Svanberg A. Satisfaction with childbirth services provided in public health facilities: Results from a cross- sectional survey among postnatal women in Chhattisgarh, India. Glob Health Action 2017;10:1386932.  Back to cited text no. 8
Gungor I, Beji NK. Development and psychometric testing of the scales for measuring maternal satisfaction in normal and caesarean birth. Midwifery 2012;28:348-57.  Back to cited text no. 9
Bitew K, Ayichiluhm M, Yimam K. Maternal satisfaction on delivery service and its associated factors among mothers who gave birth in public health facilities of debre Markos town, Northwest Ethiopia. Biomed Res Int 2015;2015:460767.  Back to cited text no. 10
Tayelgn A, Zegeye DT, Kebede Y. Mothers' satisfaction with referral hospital delivery service in Amhara Region, Ethiopia. BMC Pregnancy Childbirth 2011;11:78.  Back to cited text no. 11
Melese T, Gebrehiwot Y, Bisetegne D, Habte D. Assessment of client satisfaction in labor and delivery services at a maternity referral hospital in Ethiopia. Pan Afr Med J 2014;17:76.  Back to cited text no. 12
Matejić B, Milićević MŠ, Vasić V, Djikanović B. Maternal satisfaction with organized perinatal care in Serbian public hospitals. BMC Pregnancy Childbirth 2014;14:14.  Back to cited text no. 13
Christiaens W, Bracke P. Assessment of social psychological determinants of satisfaction with childbirth in a cross-national perspective. BMC Pregnancy Childbirth 2007;7:26.  Back to cited text no. 14
Domingues RM, Santos EM, Leal Mdo C. Aspects of women's satisfaction with childbirth care in a maternity hospital in Rio De Janeiro. Cad Saude Publica 2004;20 Suppl 1:S52-62.  Back to cited text no. 15
Mohammad KI, Alafi KK, Mohammad AI, Gamble J, Creedy D. Jordanian women's dissatisfaction with childbirth care. Int Nurs Rev 2014;61:278-84.  Back to cited text no. 16
Goodman P, Mackey MC, Tavakoli AS. Factors related to childbirth satisfaction. J Adv Nurs 2004;46:212-9.  Back to cited text no. 17
Jafari E, Mohebbi P, Mazloomzadeh S. Factors related to women's childbirth satisfaction in physiologic and routine childbirth groups. Iran J Nurs Midwifery Res 2017;22:219-24.  Back to cited text no. 18
Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women's satisfaction with maternal health care: A review of literature from developing countries. BMC Pregnancy Childbirth 2015;15:97.  Back to cited text no. 19
Sudhinaraset M, Treleaven E, Melo J, Singh K, Diamond-Smith N. Women's status and experiences of mistreatment during childbirth in Uttar Pradesh: A mixed methods study using cultural health capital theory. BMC Pregnancy Childbirth 2016;16:332.  Back to cited text no. 20
Issac A, Chatterjee S, Srivastava A, Bhattacharyya S. Out of pocket expenditure to deliver at public health facilities in India: A cross sectional analysis. Reprod Health 2016;13:99.  Back to cited text no. 21
Vellakkal S, Reddy H, Gupta A, Chandran A, Fledderjohann J, Stuckler D. A qualitative study of factors impacting accessing of institutional delivery care in the context of India's cash incentive program. Soc Sci Med 2017;178:55-65.  Back to cited text no. 22
Sudhinaraset M, Beyeler N, Barge S, Diamond-Smith N. Decision-making for delivery location and quality of care among slum-dwellers: A qualitative study in Uttar Pradesh, India. BMC Pregnancy Childbirth 2016;16:148.  Back to cited text no. 23
Gupta A, Fledderjohann J, Reddy H, Raman VR, Stuckler D, Vellakkal S. Barriers and prospects of India's conditional cash transfer program to promote institutional delivery care: A qualitative analysis of the supply-side perspectives. BMC Health Serv Res 2018;18:40.  Back to cited text no. 24
Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review. PLoS Med 2015;12:e1001847.  Back to cited text no. 25


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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