Article Type: Clinical Article

Accepted Article
Disrespect and abuse during childbirth in fourteen hospitals in nine cities of

Peru

Reneé Montesinos-Segura 1,*, Diego Urrunaga-Pastor 2, Giuston Mendoza-Chuctaya 1,

Alvaro Taype-Rondan 3, Luis M. Helguero-Santin 4, Franklin W. Martinez-Ninanqui 1, Dercy

L. Centeno 5, Yanina Jiménez-Meza 6, Ruth C. Taminche-Canayo 7, Liz Paucar-Tito 1,

Wilfredo Villamonte-Calanche 8

1
Escuela Profesional de Medicina Humana, Universidad Nacional de San Antonio Abad del

Cusco, Cusco, Peru

2
Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martin de

Porres, Facultad de Medicina Humana, Universidad de San Martin de Porres, Lima, Peru
3
CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano

Heredia, Lima, Peru

4
Sociedad Científica de Estudiantes de Medicina de la Universidad Nacional de Piura,

Facultad de Medicina Humana, Universidad Nacional de Piura, Piura, Peru

5
Sociedad Científica Medico Estudiantil San Cristobal, Escuela Profesional de Medicina

Humana. Universidad Nacional de San Cristóbal de Huamanga, Ayacucho, Peru

6
Sociedad Científica Médico Estudiantil Continental, Facultad de Medicina Humana,

Universidad Continental, Junín, Peru

7
Sociedad Científica de estudiantes de Medicina de la Amazonía Peruana, Escuela

Profesional de Medicina Humana, Universidad Nacional de la Amazonía Peruana, Iquitos,

Peru

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/ijgo.12353
This article is protected by copyright. All rights reserved.
 8
Centro de Investigación de Medicina Materno Fetal de Altura, Servicios de Salud

CENIMFA SAC, Cusco, Peru

Accepted Article
* Correspondence

Reneé Montesinos-Segura, Urb. Marcavalle A-20, Distrito de Wanchaq, Cusco, Perú.

Email: mrenee.ms@gmail.com

Keywords: Disrespect; Human rights abuse; Obstetric delivery; Obstetric labor; Patient

advocacy; Patient rights; Reproductive rights

Synopsis: Almost all women who were interviewed had experienced at least one form of

disrespect and abuse during childbirth care.

Abstract

Objective: To assess the prevalence of disrespect and abuse during childbirth and its

associated factors in Peru.

Methods: In an observational cross-sectional study, women were surveyed within 48 hours

of live delivery at 14 hospitals located in nine Peruvian cities between April and July 2016.

The survey was based on seven categories of disrespect and abuse proposed by Bowser

and Hill. To evaluate factors associated with each category, prevalence ratios (PRs) and

95% confidence intervals (CIs) were calculated by adjusted Poisson models with robust

variances.

Results: Among 1528 participants, 1488 (97.4%) had experienced at least one category of

disrespect and abuse. Frequency of abandonment of care was increased with cesarean

delivery (PR 1.27, 95% CI 1.03–1.57) but decreased in the jungle region (PR 0.27, 0.14–

0.53). Discrimination was associated with the jungle region (PR 5.67, 2.32–13.88). Physical

abuse was less frequent with cesarean than vaginal delivery (PR 0.23, 0.11–0.49). The

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 prevalences of abandonment of care (PR 0.42, 0.29–0.60), non-consented care (PR 0.70,

0.57–0.85), discrimination (PR 0.40, 0.19–0.85), and non-confidential care (PR 0.71, 0.55–
Accepted Article
0.93) were decreased among women who had been referred.

Conclusion: Nearly all participants reported having experienced at least one category of

disrespect and abuse during childbirth care, which was associated with type of delivery,

being referred, and geographic region.

1 INTRODUCTION

Disrespect and abuse during childbirth care are considered a form of violence that directly

violates women’s rights as defined by the United Nations—i.e. the right to respect, timely

care, autonomy, self-determination, and information during childbirth [1]. Thus, many

countries have issued laws that sanction acts of disrespect and abuse during childbirth.

Additionally, disrespect and abuse could have important consequences for women and their

care-seeking behaviors, such as decreased willingness to seek institutionalized delivery [2],

decreased satisfaction with received care [3], reduced confidence in health personnel and

the health system [4,5], decreased desire to have more vaginal deliveries [4], and even

reduced production of breast milk [6].

Several studies have been performed to evaluate disrespect and abuse in childbirth [7–10];

however, they have used different definitions and instruments for evaluation, making it

difficult to adequately compare their findings. Therefore, WHO has emphasized the need not

only to standardize the operational definition of disrespect and abuse, but also to develop

standardized tools for measurement [1].

In 2010, Bowser and Hill elaborated a definition of disrespect and abuse through a

systematic landscape analysis of published and grey literature, and by conducting individual

interviews with expert informants and holding a structured group discussion on the topic [11].

This article is protected by copyright. All rights reserved.

 Their definition covers seven categories: (1) non-confidential care, (2) physical abuse, (3)

abandonment of care, (4) detention in facility, (5) non-consented care, (6) discrimination, and
Accepted Article
(7) non-dignified care [11,12].

Such an extended definition of disrespect and abuse has rapidly become widespread and

has been used by the Health Policy Project to create the Respectful Maternity Care guide

[12]. It has also been used in several studies, including one in Kenya [13], one in Ethiopia

[14], three in Tanzania [5,15,16], one in Nigeria [17], and a multi-country study in Africa [18].

These studies have reported the prevalence of disrespect and abuse in childbirth to vary

between 12.2% and 98%.

Health inequity is a latent subject in Peru, where just over 20 years ago, many women of a

low educational level were pressured to undergo surgical sterilization without adequate

information and even without proper postsurgical care [19]. However, recent studies have

reported that, at present, gender discrimination does not seem to represent an important

element of the Peruvian health system [20,21].

Despite the importance of disrespect and abuse in childbirth, few studies have addressed

this issue in Latin American countries. For example, a study in Mexico evaluated only

physical abuse and non-dignified care [10], whereas two studies in Venezuela limited their

evaluation to non-consented care, physical abuse, and non-dignified care [7,8]. A study in

Brazil evaluated physical abuse and abandonment of care [9]. In Peru, one study evaluated

non-dignified care, abandonment of care, and non-confidential care [22], whereas another

evaluated non-consented care and non-confidential care for vaginal examination [23]. To our

knowledge, no study has evaluated all seven disrespect and abuse categories proposed by

Bowser and Hill in this geographic region.

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 This lack of information in Latin America makes it difficult to properly evaluate the

occurrence of disrespect and abuse, and to design and implement public policies for its
Accepted Article
prevention. Therefore, the aim of the present study was to address this gap and assess the

prevalence of disrespect and abuse in childbirth and associated factors in 14 hospitals in

nine cities of Peru.

2 MATERIALS AND METHODS

The present observational cross-sectional study was performed among women who

delivered in 14 regional hospitals located in nine urban Peruvian cities between April 1 and

July 31, 2016. The research project was approved by the Institutional Review Board of the

San Bartolome Hospital (RCEI-40), Lima, Peru. Authorization was also given by each of the

evaluated hospitals. Informed consent was obtained from participants before the survey,

when it was clarified that participation was voluntary and participants could refrain from

answering any question or leave the study at any time. It was also clarified that the choice to

take a part in the study would not change the health care delivered by the hospital.

Anonymity of the participants and confidentiality of the data were ensured.

The study hospitals were located in two cities in the coastal region (Chiclayo and Piura), five

in the highlands (Cusco, Huamanga, Huancayo, Cerro de Pasco, and Puno), and two in the

jungle (Iquitos and Tarapoto) (Figure 1). The original objective was to perform the study in

Peruvian cities with higher numbers of inhabitants, but permission was granted only in some

hospitals in some cities, where the study was ultimately performed.

The participants were women who were under observation in the hospitals after delivering a

live neonate within the past 48 hours. Women with neurocognitive disorders or who refused

to participate in the study were excluded.

This article is protected by copyright. All rights reserved.

 The survey design was based on the categories of disrespect and abuse during childbirth

proposed by Bowser and Hill [11]. For each category, a list of the items proposed by the
Accepted Article
guide of Respectful Maternity Care [12] was supplemented with other items proposed by

previous studies that also used these categories [13–17], thereby generating a list of 36

items related to disrespect and abuse during childbirth.

The final list was assessed by 17 Peruvian experts, including gynecologists, obstetricians,

and epidemiologists. Additionally, a pilot study was undertaken in seven cities (3 in coastal

regions, 3 in the highlands, and 1 in the jungle), surveying 30 women who had had a live

birth in the past 48 hours in each city. In both evaluations, experts and mothers were asked

about the clarity of each item and its relevance to the disrespect and abuse construct. The

questions were rephrased to ensure clarity among the target audience. The Spanish version

of the final survey is presented in Table S1.

A multicenter research group was formed with participants from nine cities in Peru who

received permission to conduct the survey in 14 hospitals: 10 were public hospitals

pertaining to the Ministry of Health (MINSA), and 4 were public hospitals pertaining to the

Social Security Systems (EsSalud). MINSA and EsSalud are the main healthcare systems in

Peru, providing healthcare for 37.0% and 21.0% of Peruvians, respectively [24]. EsSalud

hospitals tend to have a higher budget and are better equipped than MINSA hospitals.

Patients at MINSA facilities come mostly from rural and marginal urban areas, where the

level of poverty is higher. Comparatively, EsSalud patients are usually formal workers,

retirees, or relatives of workers and retirees.

The surveys were conducted on 3–7 days per week, depending on the availability of the

team. All women who were in the postnatal wards and met the inclusion criteria were

surveyed, and at least 100 surveys were completed in each hospital. The 100-survey

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 threshold was chosen by consensus among the researchers on the basis of the feasibility of

conducting the surveys at each hospital.

Accepted Article
For administration of the survey, the interviewers led the woman to a private room or, if this

was not possible, they verified that the hospital’s health personnel were not nearby to avoid

bias in the responses of the participants. To try to avoid changes in the treatment of the

mothers, discretion was used to ensure that most health personnel did not know that the

study was being conducted. In most cases, only the hospital’s institutional review board

knew about the study. The surveys were conducted in Spanish or Quechuan, in accordance

with the women’s language preference. Survey responses were typed independently by two

researchers into Excel 2016 (Microsoft, Redmond, WA, USA), resulting in two databases

that were subsequently compared; data that did not match were reviewed for correction.

A positive answer to at least 1 of the 36 items in the survey was taken to indicate that the

participant had experienced disrespect and abuse in childbirth. Furthermore, a positive

answer to at least one of the items corresponding to each category (non-confidential care,

discrimination based on patient’s attributes, non-consented care, non-dignified care,

abandonment of care, detention in facility, and physical abuse) was taken to indicate that the

participant had experienced that category of disrespect and abuse during childbirth. The

number of categories experienced concurrently by the participants was also determined by

evaluating how many categories had a positive response.

The following sociodemographic variables were collected: age in years, level of education,

and area of residence (urban or rural). The number of previous deliveries (0 or ≥1) and

number of prenatal care visits (dichotomized as <6 or ≥6 visits as per the cutoff point

proposed by MINSA [25]) were also recorded, along with whether the participant was

referred from another health facility for the current delivery (yes or no), type of delivery

(vaginal or cesarean), and dependence of the health facility (MINSA or EsSalud). Hospitals

This article is protected by copyright. All rights reserved.

 were categorized by their geographic region as coastal, highlands, or jungle. The rationale

for this division was the differences in hospital infrastructure and healthcare practices
Accepted Article
observed among these geographic regions.

Data analysis was performed using STATA version 14.0 (StataCorp, College Station, TX,

USA). The study data were described as absolute frequencies, relative frequencies, and

mean ± SD. To explore the factors associated with each category of disrespect and abuse,

prevalence ratios and 95% confidence intervals were calculated by using adjusted Poisson

regression with robust variance; sandwich estimators were also used on the assumption that

data would be clustered in hospitals. P<0.05 was considered to be statistically significant.

3 RESULTS

In total, 1538 postpartum women were asked to participate in the study, of whom 10 refused.

Hence, data were collected from 1528 women: 440 (28.8%) in hospitals of the coastal

region, 659 (43.1%) in the highlands, and 429 (28.1%) in the jungle. The overall prevalence

of having experienced at least one category of disrespect and abuse was 1488 (97.4%). The

values ranged from 70.0% to 100% across the 14 hospitals studied (Table 1).

The respondents had a mean ± SD age of 26.6 ± 6.3 years; 937 (61.4%) of 1526 had at

least one previous delivery; and 968 (63.4%) of 1528 had a vaginal delivery in the index

pregnancy (Table 2).

Regarding the different categories, the most prevalent form of disrespect and abuse was

non-dignified care (86.2% [1296/1504]), followed by non-consented care (74.6%

[1101/1475]), and non-confidential care (68.1% [1037/1523]) (Table S2). Figure 2 shows the

number of concurrent categories of disrespect and abuse reported. The number of women

who experienced two or more categories of disrespect and abuse concurrently was 1358

(88.9%), whereas that of women who experienced four or more categories concurrently was

850 (55.6%).

This article is protected by copyright. All rights reserved.

 Factors associated with experiencing each category of disrespect and abuse were

assessed by adjusted models, which showed that women who delivered by cesarean
Accepted Article
had a higher prevalence of abandonment of care and a lower prevalence of physical

abuse as compared with women who delivered vaginally (Table 3). Women referred

from other health facilities had a lower prevalence of abandonment of care, non-

consented care, discrimination, and non-confidential care as compared with women

who were not referred (Table 3). With regard to geographic region, abandonment of

care was significantly more common in the coastal region than in the jungle, whereas

discrimination was significantly more common in the jungle than at the coast (Table

3).

4 DISCUSSION

Almost all the postpartum women surveyed in the present study had experienced at least

one of the categories of disrespect and abuse during childbirth. Non-dignified care was the

most common form of disrespect and abuse, followed by non-consented care, and non-

confidential care. More than half of all participants experienced at least four categories of

disrespect and abuse concurrently. Type of delivery, referral from other health facilities, and

geographic region were associated with at least one form of disrespect and abuse; however,

the associated factors differed for each category.

The present prevalence of disrespect and abuse (97.4%) is similar to the level found in a

hospital in Nigeria (98%) [17], but higher than that found in four hospitals and three health

centers in Ethiopia (78.6%) [14]. It is also higher than the percentage reported in one

hospital in Tanzania (15.0%) [16], eight hospitals in Tanzania (18.0%) [5], and 13 hospitals

in Kenya (20%) [13]. The previous studies used the same definitions for the categories of

disrespect and abuse as the present study, but used fewer items: whereas 36 items were

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 used in the present study, the studies in Nigeria, Tanzania, Ethiopia, and Kenya used 28, 28,

23, and 10 items, respectively [13,14,16,17].

Accepted Article
On the basis of the high prevalence of disrespect and abuse identified in the present study,

interventions should be promptly implemented. One of the main causes of disrespect and

abuse is possibly the lack of information and lack of training for health personnel. Face-to-

face and virtual training might be used to enhance the capability of healthcare workers, and

the importance of education to empower women should be emphasized. For example,

human resource centers for women to make complaints of disrespect and abuse safely and

comfortably might be implemented. The efficacy of these interventions might be gauged by

measuring the prevalence of disrespect and abuse at various time intervals.

Other important features in the present context are the deficiencies in the infrastructure for

childbirth care, such as a lack of room availability, blinds, and health personnel, and

dissatisfaction among health personnel [25]. These aspects require further study in addition

to intervention.

Non-dignified care was the most prevalent category in the present study, which is similar to

the findings of a study in Kenya [13], but different from studies in Nigeria [17] and Tanzania

[16]. In the two latter countries, the most prevalent categories were non-consented care [17]

and abandonment of care [16], respectively. Such differences indicate that disrespect and

abuse during childbirth is dependent on context, meaning that approaches specific to each

setting are required.

The prevalence of disrespect and abuse was found to differ across hospitals. Furthermore,

individual categories such as discrimination and abandonment of care were different across

geographic regions. This suggests that these problems should not be uniformly addressed

This article is protected by copyright. All rights reserved.

 throughout the country, and that each hospital and geographic region should prioritize

interventions according to their particular context.

Accepted Article
The present study also found a high prevalence of women experiencing more than one

category of disrespect and abuse. This aspect has not been evaluated in previous studies.

Experiencing more than one category might have increased consequences for women in

terms of dissatisfaction with the healthcare system, decreased use of institutional delivery,

and depression. Future studies should assess the prevalence and consequences of multiple

abuses.

The prevalence of discrimination was lower in the coastal region (9.1%), higher in the

highlands (25.8%), and highest in the jungle (75.8%). These statistics might reflect a greater

vulnerability of the Peruvian population in the highlands and jungle, differences in the

perception of discrimination among regions, or differences in training of the health personnel

among these geographic regions.

Abandonment of care was more common in the coastal region than in the highlands or the

jungle. Within this category, a refused request to have a companion present during delivery

was most prevalent. This might be attributed to the smaller and more overcrowded labor

rooms in hospitals in the coastal region as compared with the highlands or jungle, which

makes it difficult to allow the presence of a birth companion. Such a restriction violates the

protocol of care established by the Ministry of Health of Peru, which promotes the

participation of a companion chosen by the pregnant woman throughout their labor [25].

Cesarean delivery was found to be a protective factor against physical abuse, possibly

because women who deliver by cesarean undergo fewer procedures relative to those who

have vaginal delivery involving, for example, Kristeller maneuver or episiotomy without

This article is protected by copyright. All rights reserved.

 anesthesia. However, it was also associated with abandonment of care, possibly due to the

complexity of having a companion during pre-cesarean preparation.

Accepted Article
Referral from other health centers was also considered to be a protective factor in several

categories of disrespect and abuse. This might be because referred women arrive during an

advanced stage of labor and spend less time in the hospital. Moreover, they are often

referred because they present risk factors or obstetric complications, meaning that they

receive more attention and accompaniment.

The present study has some limitations. First, the aim was to generate a validated survey of

disrespect and abuse suitable for all Peruvian hospitals; however, each geographic region

has its own unique cultural features and traditions. As a result, it is possible that some of the

items listed in the survey were not part of the disrespect and abuse construct in some

contexts. Moreover, although the present study aimed to use the same categories of

disrespect and abuse as other studies [5,13–15,17,18], the number of items varied in

previous investigations. Second, the length of the survey was a limiting factor, as also

reported in other studies [16,17]. Third, the participants might have felt intimidated by the

hospital environment, which in turn might have influenced their responses; however, the

interviewers emphasized the anonymity of the survey and, in an attempt to reduce this bias,

conducted the survey when no health personnel were in the room. Fourth, only women who

had delivered in the past 48 hours were surveyed; this population of women could have

been affected by immediate distressing factors related to labor, which might have influenced

their answers; however, this limitation is shared by previous studies [14–16].

The study also has strengths. To our knowledge, it is the first to evaluate the seven

categories of disrespect and abuse during childbirth in health facilities in a Latin American

country, and one of the few studies to have been performed in several hospitals and more

This article is protected by copyright. All rights reserved.

 than one city. As a result, it provides much information for the development of public policies

to tackle disrespect and abuse in Peru and other countries.

Accepted Article
In conclusion, the present investigation found that almost all women surveyed had

experienced at least one category of disrespect and abuse during childbirth care.

There were differences in the overall prevalence across hospitals and geographic

regions. The following factors were associated with at least one category of

disrespect and abuse: type of delivery (i.e. vaginal or cesarean), referral from

another health facility, reliability of the health facility, and geographic region. The

findings indicate that interventions to reduce the prevalence of disrespect and abuse

should be promptly implemented, with different approaches in each region.

Author contributions

RM-S, AT-R, and WV-C designed the study. RM-S and AT-R trained the interviewers for

data collection. RM-S, LMH-S, FWM-N, DLC, LP-T, YJ-M, and RCT-C collected the data.

RM-S, DU-P, GM-C, LMH-S, and AT-R performed the statistical analyses. All authors

participated in data interpretation and manuscript preparation, and all approved its final

version.

Acknowledgments

Sheyla Yucra-Soto assisted with the design of the study. Laura R. Arce-Villalobos, Elvia

Vicente-Guerra, Pamela D. Flores-Gonzales, and Liussmyth S. Vega assisted with data

collection and typing the survey results. Safia S. Jiwani, Jessica Zafra-Tanaka, Maria Lazo-

Porras and J. Jaime Miranda critically reviewed the manuscript. The present research was

partly funded by Sociedad Científica Médico Estudiantil Peruana. Other outgoings were self-

financed by the authors.

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 Conflicts of interest

The authors have no conflicts of interest.

Accepted Article
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Figure legends

Figure 1 Map of the nine cities in Peru where the study was conducted.

Figure 2 Number of concurrent categories of disrespect and abuse in childbirth

reported by the study women.

Supporting information legends

Table S1 The study survey in Spanish.

Table S2 Prevalence of items in each category of disrespect and abuse in childbirth.

Table 1 Characteristics of the hospitals where the study was performed, by geographic region.

Hospital Dependence No. of surveys Prevalence of disrespect and

a
analyzed abuse
Coastal
Hospital 1 MINSA 110 109 (99.1)
Hospital 2 MINSA 110 110 (100.0)
Hospital 3 EsSalud 110 110 (100.0)
Hospital 4 EsSalud 110 110 (100.0)
Highlands
Hospital 5 MINSA 110 110 (100.0)
Hospital 6 MINSA 100 110 (100.0)
Hospital 7 MINSA 100 70 (70.0)
Hospital 8 MINSA 129 126 (97.7)
Hospital 9 MINSA 110 110 (100.0)
Hospital 10 EsSalud 110 109 (99.1)
Jungle

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 Hospital 11 MINSA 110 110 (100.0)
Hospital 12 MINSA 110 110 (100.0)
Hospital 13 MINSA 99 95 (96.0)
Accepted Article
Hospital 14 EsSalud 110 110 (100.0)

Abbreviations: MINSA, Ministry of Health of Peru; EsSalud, Social Security System of Peru.
a
Values are given as number (percentage).

a
Table 2 Sociodemographic characteristics of the study population (n=1528).

Characteristic Value
Age, y 26.6 ± 6.3
13–23 525 (34.4)
24–29 520 (34.0)
30–45 483 (31.6)
Level of education
No formal education/primary only 515 (33.7)
≥1 y of secondary education 517 (33.8)
≥1 y of higher education 496 (32.5)
Area of residence
Urban 1254 (82.1)
Rural 273 (17.9)
b
Previous deliveries
0 589 (38.6)
≥1 937 (61.4)
Prenatal care visits
<6 422 (27.6)
≥6 1106 (72.4)
Type of delivery
Vaginal 968 (63.4)
Cesarean 560 (36.6)
Referred from another health facility
No 935 (61.2)
Yes 593 (38.8)
Dependence
Ministry of health 1088 (71.2)
EsSalud 440 (28.8)
Geographic region
Coast 440 (28.8)
Highlands 659 (43.1)
Jungle 429 (28.1)
a
Values are given as mean ± SD or number (percentage).
b
Data missing for 2 participants.

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ccepted Articl a
Table 3 Adjusted analysis of the factors associated with each category of disrespect and abuse.

Variable Physical abuse Abandonment of Non-dignified care Non-consented Discrimination Non-confidential

care care care
Age group, y
13–23 Ref. Ref. Ref. Ref. Ref. Ref.
24–29 1.01 (0.85–1.19) 0.99 (0.82–1.20) 1.00 (0.95–1.05) 1.04 (0.98–1.11) 0.99 (0.79–1.24) 1.00 (0.92–1.08)
30–45 1.01 (0.85–1.21) 0.92 (0.73–1.17) 0.99 (0.91–1.08) 0.95 (0.87–1.05) 1.00 (0.72–1.37) 0.91 (0.79–1.05)
Level of education
No formal education/ Ref. Ref. Ref. Ref. Ref. Ref.
primary only
≥1 y of secondary 0.84 (0.70–1.02) 1.02 (0.76–1.38) 1.00 (0.92–1.08) 0.78 (0.58–1.04) 0.75 (0.46–1.24) 0.89 (0.73–1.10)
education
≥1 y of higher 0.88 (0.68–1.14) 1.37 (0.93–2.04) 1.08 (0.98–1.19) 0.83 (0.60–1.15) 0.94 (0.53–1.66) 0.89 (0.72–1.09)
education
Area of residence
Urban Ref. Ref. Ref. Ref. Ref. Ref.
Rural 1.00 (0.82–1.22) 1.09 (0.87–1.38) 1.06 (0.99–1.13) 0.84 (0.65–1.09) 1.26 (0.58–2.74) 0.98 (0.79–1.22)
Previous deliveries
0 Ref. Ref. Ref. Ref. Ref. Ref.
≥1 1.00 (0.92–1.08) 1.08 (0.93–1.25) 1.02 (0.95–1.08) 0.99 (0.91–1.08) 1.05 (0.84–1.31) 1.00 (0.94–1.07)
Prenatal care visits
<6 Ref. Ref. Ref Ref. Ref. Ref.
≥6 0.96 (0.83–1.10) 1.20 (0.88–1.65) 1.00 (0.94–1.07) 0.91 (0.77–1.08) 0.97 (0.74–1.28) 0.97 (0.84–1.13)
Type of delivery
Vaginal Ref. Ref. Ref. Ref. Ref. Ref.
Cesarean 0.23 (0.11–0.49) 1.27 (1.03–1.57) 1.11 (0.96–1.29) 1.02 (0.90–1.16) 0.84 (0.58–1.21) 1.11 (0.93–1.33)
Referred from another
health facility
No Ref. Ref. Ref. Ref. Ref. Ref.
Yes 0.76 (0.58–1.01) 0.42 (0.29–0.60) 0.85 (0.69–1.04) 0.70 (0.57–0.85) 0.40 (0.19–0.85) 0.71 (0.55–0.93)
Dependence
Ministry of health Ref. Ref. Ref. Ref. Ref. Ref.
EsSalud 1.19 (1.03–1.37) 0.67 (0.40–1.11) 0.98 (0.90–1.07) 0.99 (0.78–1.25) 0.72 (0.36–1.43) 0.99 (0.86–1.16)
Geographic region

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ccepted Articl Coast
Highlands
Jungle
Ref.
1.03 (0.78–1.36)
0.79 (0.57–1.09)
Ref.
0.69 (0.39–1.20)
0.27 (0.14–0.53)
Ref.
0.80 (0.66–0.98)
1.06 (0.97–1.15)
Ref.
0.96 (0.80–1.14)
0.78 (0.47–1.32)
Ref.
2.48 (0.81–7.54)
5.67 (2.32–13.88)
Ref.
0.96 (0.76–1.22)
1.07 (0.78–1.47)

a
Values are given as prevalence ratio (95% confidence interval) and were calculated using adjusted Poisson regression with robust variance; sandwich
estimators were also used on the assumption that data would be clustered in hospitals. Adjusted for all variables included in the table. The category
“Detention in facility due to non-payment” was not evaluated owing to the low number of outcomes.

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Accepted Article

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 30%
Proportion of participants, %
25%
Accepted Article
20%

15%

10%

5%

0%
0 1 2 3 4 5 6 7
No. of concurrent categories

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