br Funding This work was supported

Funding
This work was supported by the Swedish Research Council for Health, Working Life and Welfare (FORTE) under Grant number 2014-0445 for Jenny Torssander, and by the University of Copenhagen for Laust H Mortensen.

Body
Reports of disrespectful maternity care are emerging worldwide, despite protections against abusive treatment of women in health care settings as outlined in formal international Conventions on human rights (United Nations Commission on the Status of Women, 2016; Oviedo, 1997). Bowser and Hill\’s groundbreaking landscape analysis (Bowser & Hill, 2010) provides an evidence-based definition of disrespect and abuse in childbirth which includes seven domains: “physical abuse, non-consented care, non-confidential care, non-dignified care (including verbal abuse), discrimination based on specific attributes, abandonment or denial of care, detention in facilities”. Bohren and colleagues, from the WHO Research Group on the Treatment of Women During Childbirth (Bohren et al., 2015) conducted a mixed methods systematic review of 65 studies across 34 countries and concluded that there is no consensus at a global level on how disrespectful maternity care is measured. Their review added the domains of “poor rapport between women and providers, including ineffective communication, lack of supportive care, and loss of autonomy”, to Bowser\’s examples of abuse and disrespect in childbirth. Bohren et al.’s paper ends with an urgent call to develop “validated and reliable research tools to measure the mistreatment of women in childbirth.” (Bohren et al., 2015).

Methods
In 2012, our team was funded by the Vancouver Foundation to conduct a provincial community-led participatory action research (CBPR) project entitled “Changing Childbirth in BC: Women exploring access to high quality maternity care.” A diverse harpagoside of childbearing women worked alongside community partners (e.g. leaders from non-governmental service agencies) and university researchers to design a mixed-methods study of maternity care in British Columbia (BC). Recognizing diversity in their perspectives and lived experience, the group self-organized into four work groups to address the needs of immigrant and refugee women, formerly incarcerated women, women facing multiple social and economic barriers, as well as midwifery and physician service users from urban and rural settings.
A community consultation with 1333 women determined key areas for study, and preferred modes of data collection and survey distribution. Based on their recommendations, the team developed a cross-sectional online survey to assess preferences for model of care, experiences of decision making and respectful care, and access to maternity care providers. An extensive content validation process included a literature review, an expert panel review, and community specific modifications by work groups. The CBPR process resulted in creation of four population-specific versions of a one-hour online survey that collected data on socio-demographics, preferences for maternity care, the process of decision-making, access to maternity providers, and experiences of care during the childbearing cycle.

Results

Discussion
Measuring respectful care over the childbearing cycle requires thoughtful assessment of several domains. We have constructed a reliable and validated instrument that assess the culture of dialogue in maternity care. The MOR index is a straightforward tool to measure the experience of respect during discussions with providers about maternity care options. The index captures a complex set of effects and interactions related to three domains within the experience of respectful maternity care: 1. a woman\’s sense of autonomy and comfort when accepting or declining care options, 2. evidence of the woman modifying her behavior as a result of fear of anticipated disrespect, and 3. perceived differential treatment as a result of a non-modifiable socio-demographic factor. The significance of the first two domains is supported by findings of Lukasse et al. (2015) that loss of agency and poor treatment leads to fear. The third dimension, differential treatment based on race, ethnicity or personal characteristics, measures the occurrence of violations related to stigma and discrimination as described by both Bowser and Bohren (Bohren et al., 2015; Bowser & Hill, 2010).