# How health system failures and prevailing social norms drive mistreatment of women in maternity care in Ethiopia: a qualitative study

## TL;DR

This study explores how poor health systems and harmful social norms in Ethiopia lead to the mistreatment of women during maternity care.

## Contribution

The study identifies multi-level drivers of mistreatment in maternity care, integrating socioecological and quality of care frameworks.

## Key findings

- Health system issues like under-resourcing and staff burnout contribute to mistreatment of women.
- Societal norms and gender-based violence influence healthcare providers' behaviors toward women.
- Addressing these issues requires systemic changes and community engagement to promote respectful care.

## Abstract

Mistreatment of women during maternity care is a widespread global issue, particularly in low- and middle-income countries where health disparities intersect with rigid gender norms, systemic inequality and domestic violence.

This paper aims to explore how health system failures and societal norms against women contribute to the mistreatment of women during maternity care.

A qualitative study was conducted among maternal healthcare providers in the East Wollega Zone, Ethiopia. In-depth interviews with purposively selected participants in Afan Oromo, each lasting 30–60 min, were conducted until data saturation was reached at 20 interviews. The interviews were audio-recorded, transcribed, translated into English, coded using NVivo 12 and analysed through thematic analysis guided by the Socioecological and Quality of Care frameworks.

Health system conditions and constraints, such as under-resourcing and issues related to governance and providers’ prejudices shaped by societal norms, were found to drive mistreatment of women during maternity care. These drivers manifest at various levels throughout the healthcare system, including personal, interpersonal, facility-level, health system and societal dimensions. Overcrowding, staff shortages and low pay led to burnout, which eventually resulted in mistreatment of women. The lack of recognition from administrators and professional hierarchies also added to provider frustration, which was sometimes directed at women. Societal issues, like gender-based violence, further influenced these behaviours.

Mistreatment of women during maternity care continues to hinder the delivery of quality care. Addressing gender inequality, boosting healthcare worker motivation and ensuring fair treatment among staff are essential for promoting respectful maternity care.

Main findings: This study presents a qualitative study that involved maternal healthcare providers to explore the underlying drivers of the mistreatment of women during maternity care in western Ethiopia through integrating data obtained from participants with the socioecological frameworks for violence against women and WHO’s Quality of Care.

Added knowledge: The interpretive qualitative analysis identified factors contributing to the mistreatment of women stemming from individual, interpersonal, institutional, systematic and societal origins. These drivers are manifestations of broader issues in the under-resourcing, governance and social norms in the study area, which demand strategic actions to fully prevent the mistreatment of women in health facilities during maternity care.

Global health impact for policy and action: This study offers insights to inform health policies and practices to improve service delivery by fostering a health system that supports its caregivers, engages communities and eliminates gender-based violence.