More women had post-secondary education and belonged to the uppermost wealth quartile in the public hospital rather than those in the private one. This finding could be because in the context of the study area, teaching hospitals (the public hospital in this study) are well known to offer a wider range of specialist care in addition to employing higher numbers of skilled health workers and these may be better appreciated and sought after by those who are more educated and can better afford this care because they are in the upper wealth quartiles. However, the population in these two hospitals may be different from the distribution of education and wealth quartiles in the general population in Nigeria [9, 33].
The prevalence of abandonment and neglect during childbirth was the major category of D&A experienced in both hospitals. These were all statistically significantly higher in the public hospital as compared to the private hospital. The difference in prevalence of abandonment/neglect during childbirth between the public and private hospital could be because the public hospital is a bigger referral hospital (the only teaching hospital in the State) and may also have more women referred for complications than the private hospital. This could overwhelm the ability of the staff leading to perceived feelings of being abandoned. On the other hand, staff may become more friendly with women who have complications than with those who have no complications. Consistent with our findings, abandonment was among the most reported forms of D&A during childbirth in other studies [19, 23, 34,35,36]. This high prevalence of abandonment is particularly worrisome because the assured availability of a health provider during childbirth is an aspect of care considered important by women who have passed through the childbirth process . Under this abandonment category, being denied companionship in labour by the husband or close relatives was most often reported. Companionship during labour and childbirth have been found to improve maternal mental wellbeing and obstetric outcomes . Nonetheless, implementation of this effective and affordable intervention has remained suboptimal in many settings such as ours [38, 39]. On the other hand, non-consented and non-dignified care were most commonly reported in other studies [18, 40].
In contrast to our findings, other studies (also in teaching hospitals) found higher proportions of non-consented care during childbirth (54%-100%) . An explanation could be that women in those studies were interviewed earlier after birth than in ours. Findings from other studies are consistent with the different forms of non-consented care in our study [18, 23, 34, 41]. In line with ethical best practices, informed consent is supposed to be obtained from women before any procedure is carried out. These reports of non-consented care are a breach of ethical principles and highlight the need to improve ethics-based obstetric practices. One reason for this could be that in resource–limited environments, litigations related to such matters are relatively uncommon and the implicit assumption that health providers are to make decisions regarding maternity care for women with or without their informed consent [18, 42].
Non-dignified care was also commonly reported in this study however more respondents (29.6%) experienced non-dignified care in another Nigerian study , while it was the commonest type of D&A meted out to women during childbirth in Mali .
Discriminatory care during childbirth has been documented in our and other studies [18, 44]. Discriminating against a parturient for any reason breaches the fundamental health rights of women. Thus there is need for continuous training and supervision of obstetric healthcare providers in order to ensure non-discrimination in patient care.
The prevalence of at least one form of D&A during childbirth was high in both hospitals, but significantly higher in the public hospital.
Women were interviewed in the health facility where their childbirth had occurred and this could have introduced courtesy bias. It has been suggested, however, that a longer period after birth may allow time for mental processing the birth experience and thus improve recall. Alternatively, a different school of thought opines that women may tend to forget the nasty birth experiences the longer the time passed between the experience and the survey . A study among women in Ethiopia, Kenya, Madagascar, Rwanda and Tanzania reported a prevalence of 60% of overall violations of respectful maternity care rights following objective assessment using a structured checklist . Observation of women-provider interactions by trained observers in an Ethiopian study found a prevalence of 74.8%, nonetheless, only 22% of the women reported D&A during childbirth . Normalization of D&A during childbirth by mothers in the study may have made them fail to consider and/or report certain disrespectful practices leading to the incongruence between observed and self-reported events. Objective assessment of D&A by trained observers using structured checklists have shown to provide higher prevalence estimates of D&A during childbirth than subjective reporting . Self-reported prevalence of D&A during childbirth in our study may thus have been underestimated. A review of D&A during childbirth in Ethiopia and sub-Saharan Africa found a pooled prevalence of 44%-49.4% [35, 36]. Beyond being pooled estimates, the lower prevalence in these reviews may be because some of those studies were community-based and involved women at different points in time after birth.
Disparities that could account for the prevalence of at least one form of D&A in both hospitals include the fact that private hospitals, especially mission hospitals, tend to have more stringent measures in place to ensure respect for women. This includes close supervision of staff and oversight of the facility by the church, ready patient’s access to hospital or church management for complaints of disrespectful care and follow-up of such complaints in addition to the moralistic undertone with which care is rendered in private hospitals. Also, such hospitals may attract patronage from faithful people who may have more religion-related acceptance for provided health care. In contrast, bureaucratic processes, poor ownership attitudes by workers and loose redressing mechanisms have been associated with public hospitals [47, 48].
Our findings portray the need to improve maternity experiences of parturient and build an institutional culture of respectful care. This will include systematic identification of underlying contributors to D&A during childbirth as well as designing and implementing context-specific interventions to address these in the two facilities. Such interventions may involve development of institutional indicators of D&A during childbirth, their routine evaluation and using lessons learned to improve maternity experiences of women during childbirth. It is equally important to institutionalize continuous provider training, mentorship, monitoring and supportive supervision that build interpersonal communication skills aimed at promoting woman-centred care in both public and private health care settings. Such training can be integrated into existing facility-based continuous educational platforms such as grand rounds, professional group seminars and morning reviews. This is in addition to the use of provider-independent mechanisms and checks such as automated and administrative processes that routinize procedures such as informed consent before clinical care is provided. An emerging nascent area of focus from our study is the need for cross-learning and collaboration between the public and private health sectors, all geared towards improving maternal experiences of maternity care.
Previous studies have shown that women who resided in rural areas reported less D&A during childbirth than those residing in urban areas, in line with our findings [49, 50]. In other studies, being older than 19 years, having no formal education, at least ninth grade and secondary education, self-reported depression, absence of support persons during childbirth, longer labour duration, and birth via Caesarean section were more likely to experience D&A during childbirth while parity (more than four births) reduced the likelihood [49,50,51].
Women who reside in rural areas tend to be poorer, less educated, less equipped with materials for childbirth, less aware of their rights and thus more prone to experience D&A during labour and childbirth without recognizing it. Structural gender inequities evidenced by paucity of information, lack of financial stability and autonomy to exercise rights contribute to perpetuating D&A during childbirth . Additionally, rural women may be more inclined to consider such ‘mistreatments’ as normal given culture-related patriarchal settings of rural African communities and expected subservience of women . Their urban counterparts may be more knowledgeable about their rights and have higher expectations regarding their healthcare experiences with more openness in sharing D&A during childbirth. These findings highlight the need for intersectoral collaboration targeted at improving the status of women through female education, financial empowerment, awareness of rights and support for justice.
Some areas for future research would include the use of observations in estimating the prevalence and isolating enablers of D&A during childbirth from the perspectives of women and health providers in a larger number of public and private hospitals. Future research is also needed to develop and assess the effectiveness of contextually relevant interventions to reduce D&A during childbirth in both public and private health care settings.
Strengths and limitations
This is one of the few studies in Nigeria that have estimated prevalence of D&A during childbirth with quantitative methods. More so, to the best of our search, this is one of the first studies to compare experiences of D&A in public and private health care settings. Lastly, this study utilized a fairly large sample. Some limitations include the fact that it was conducted in only two facilities which were non-randomly selected. Additionally, the fact that women who did not return to immunization clinics could not be interviewed, was a possible source of selection bias. This study was not based on observational data, but on self-reports which is prone to courtesy bias. Use of the Bowser and Hill’s framework for D&A during childbirth did not permit exploitation of professional and structural/systemic definitions of mistreatment during childbirth as defined by Bohren et al. 
The survey was conducted in a hospital setting and by health workers, thus introducing courtesy bias due to women’s fear of aftermaths and non-confidentiality of their responses. Normalization of D&A during childbirth and fear of indicting health workers may have led to socially desirable responses. These could have resulted in underestimation of D&A during childbirth in both facilities. To mitigate this, different domains of D&A during childbirth were thoroughly explained and women were encouraged to give sincere responses. They were also assured of confidentiality and non-penalization for their responses.
Recall bias could have affected responses, given that the study was conducted from childbirth to 14 weeks thereafter. Conversely, a short recall period may lead to underreporting as women may be too fatigued to accurately relate their birth experiences. A longer recall period affords more time for women to recollect and correctly report their experiences. On the other hand, women may tend to forget these experiences as the newborn develops well . Involvement of the researcher and other health providers in data collection may have introduced observer bias possibly underestimating the burden of D&A during childbirth. The researchers, however, were not directly involved in maternity care and were trained on data collection techniques. Finally, this study was conducted in only two facilities offering specialist care and given the age and educational profiles of the participants, it may not be generalizable to lower levels of care and the general population.
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