Self-Compassion and Emotion Dysregulation Mediate the Effect of Stress Appraisals on Elder Abuse and Neglect Behaviors in Dementia Family Caregiving.

OBJECTIVES: The purpose of this paper is to evaluate the mechanistic process by which family caregivers' situational stress-appraisals of behavioral symptoms (BSD) increases the likelihood of a caregiver engaging in abusive and neglectful behaviors towards their care recipient with dementia. We test the hypotheses that (1) the effect of daily BSD stress-appraisals on elder abuse and neglect (EAN) is mediated by the caregivers' emotion dysregulation (2) and the mediation path is moderated by self-compassion. METHODS: This study employed a multi-time series design in which participants (N=453) completed traditional longitudinal surveys at enrollment followed by 21 sequential days of diary surveys (n=9,513). The hypothesized moderated mediation path was evaluated through a multilevel structural equation model. RESULTS: Hypotheses were supported. At the within-person level daily BSD stress appraisal has a significant direct effect on daily EAN. At the between-person level the path was no longer significant implying a full mediation of emotion dysregulation. The main effect of self-compassion, and the interaction term (emotion dysregulation x self-compassion), were also statistically significant indicating the path between emotion dysregulation and EAN is moderated by self-compassion. DISCUSSION: This study significantly advances the field by empirically showing a mechanistic pathway for a theoretical explanation of EAN. These findings represent a breakthrough for the field and identify modifiable intervention targets for future behavioral interventions to prevent EAN. Emotion (dys)regulation and self-compassion are modifiable traits and skills that can be learned, with robust evidence-bases of efficacious interventions that can be adapted for context to dementia family caregiving.

Exploring Overt Racial and Ethnic Conflict in Resident-to-Resident Aggression in Long-Term Care Facilities.

Objectives: Resident-to-resident aggression (RRA) in long-term care facilities is gaining recognition as a serious problem. Racial/ethnic conflict may be a contributing factor to RRA incidents, but it remains insufficiently studied. Our goal was to explore overt racial/ethnic conflict in RRA. Design: We used quantitative and qualitative secondary analyses of existing data from a large, rigorously conducted study of RRA to describe the involved residents and patterns of overt racial/ethnic conflicts. Setting and Participants: The parent study included information of 2011 residents in 10 randomly selected New York State nursing homes with a wide range of racial/ethnic minority residents (4.2%-63.2%). A subset of 407 residents were involved in RRA. Methods: We re-examined data from the parent study, which used an innovative approach to identify RRA incidents by reconstructing each incident based on residents' self-reports, staff interviews, field observations, and medical chart review. Resident and facility information was collected. Results: A total of 35 residents (8.6% of those involved in RRA incidents) were identified as involved in overt racial/ethnic conflicts. These residents were more likely to have had less education than residents involved in other types of RRA but not in overt racial/ethnic conflicts. More than half (56.9%) of the 51 incidents of RRA involving overt racial/ethnic conflict between a specific pair of residents occurred repeatedly. Manifestation of racial/ethnic conflicts included physical violence, discrimination, racial/ethnic slurs, stereotypes, and microaggression. Acute precipitants of these incidents included various communal-living challenges and unmet needs at the facility, relational, and individual levels. Psychological and behavioral consequences were also described. Conclusion and Implications: We found a broad range of manifestations, acute precipitants, circumstances surrounding, and consequences of overt racial/ethnic conflicts in RRA. Additional research is needed to improve understanding of this phenomenon and how staff may effectively intervene and prevent it.

Building resilience: A specialty clinic tailored to older adults at risk of violence and abuse.

OBJECTIVE: Both structural (e.g., ageism) and personal (e.g., stigma) barriers hinder older adult's access to and engagement with mental health care). These barriers are particularly problematic for those vulnerable to interpersonal violence and abuse (e.g., due to social isolation). This study presents a quality improvement program aimed at older adults who have experienced significant stress events, particularly elder mistreatment, within a larger trauma specialty clinic. Leveraging home-based telemedicine, the clinic provides evidence-based psychotherapy tailored to older adults' needs. METHODS: From 2021 through 2023, the authors retrospectively examined treatment initiation, engagement, completion, and clinical outcomes among 231 older adults age 60+ who reported trauma that met DSM-5 criterion A criteria for Post-traumatic Stress Disorder (PTSD), depression and other mental health comorbid conditions related to their traumatic event. The clinic uses an automated measurement-based care approach that facilitates Quality Improvement projects, allowing us to track treatment initiation, engagement, completion, and clinical outcomes for all patients. RESULTS: The results indicated high treatment completion, high engagement with telemedicine-delivered interventions, and, most importantly, significant changes in clinical outcomes. CONCLUSION: These findings highlight the importance of expanding telemedicine-based mental health services for older adults, challenging ageist norms, and prioritizing older adults' mental health needs by providing tailored services to this patient population.

How Identity Impacts Bystander Responses to Workplace Mistreatment.

Integrating a social identity approach with Cortina's (2008) theorizing about selective incivility as modern discrimination, we examine how identification-with an organization, with one's gender, and as a feminist-shapes bystanders' interpretations and responses to witnessed incivility (i.e., interpersonal acts of disrespect) and selective incivility (i.e., incivility motivated by targets' social group membership) toward women at work. We propose that bystanders with stronger organizational identification are less likely to perceive incivility toward female colleagues as discrimination and intervene, but female bystanders with stronger gender identification are more likely to do so. Results from two-wave field data in a cross-lagged panel design (Study 1, N = 336) showed that organizational identification negatively predicted observed selective incivility 1 year later but revealed no evidence of an effect of female bystanders' gender identification. We replicated and extended these results with a vignette experiment (Study 2, N = 410) and an experimental recall study (Study 3, N = 504). Findings revealed a "dark side" of organizational identification: strongly identified bystanders were less likely to perceive incivility as discrimination, but there were again no effects of women's gender identification. Study 3 also showed that bystander feminist identification increased intervention via perceived discrimination. These results raise doubts that female bystanders are more sensitive to recognizing other women's mistreatment as discrimination, but more strongly identified feminists (male or female) were more likely to intervene. Although strongly organizationally identified bystanders were more likely to overlook women's mistreatment, they were also more likely to intervene once discrimination was apparent.

Does mistreatment during institutional childbirth increase the likelihood of experiencing postpartum depressive symptoms? A prospective cohort study in Nepal.

BACKGROUND: Postpartum depression is associated with low socioeconomic status, adverse birthing processes, and life stress. Increasing evidence of mistreatment during childbirth, negative birth experiences, and poor quality of maternal care is of global concern. OBJECTIVE: To assess the risk of experiencing depressive symptoms among postpartum women exposed to mistreatment during institutional birthing in Nepal. METHOD: We conducted a prospective cohort study from 29 March to 19 August 2022. Of 1629 women who gave birth in a hospital in Nepal, 1222 were assessed for mistreatment during childbirth and depressive symptoms using the Edinburgh Postnatal Depression Scale. We used binomial generalized linear mixed model to examine the risk ratio of postpartum depressive symptoms in women exposed to mistreatment during childbirth. RESULTS: The prevalence of postpartum depressive symptoms was 4.4%. Women exposed to mistreatment during childbirth were almost fifty percent more likely to have postpartum depressive symptoms (cRR 1.47; 95% CI 1.14, 1.89; p = 0.003) compared with the unexposed group. Furthermore, adolescent mothers exposed to mistreatment during childbirth had a seventy percent increased risk of depressive symptoms (aRR 1.72; 95% CI 1.23, 2.41; p = 0.002). Similarly, women who gave birth to female infants were thirty percent more likely to experience postpartum depressive symptoms (aRR 1.32; 95% CI 1.01-1.74; p = 0.039). CONCLUSION: We observed an association between postpartum depressive symptoms and mistreatment during institutional births in Nepal. The implementation of appropriate respectful maternity care during childbirth and also routine screening for depressive symptoms is critical to improving perinatal mental health and well-being.

Main findings: Despite widespread reports of mistreatment during childbirth in health facilities, little is known about possible association with poor perinatal mental health outcomes.Added knowledge: This prospective cohort study in Nepal found an association between postpartum depressive symptoms and mistreatment during institutional childbirth.Global health impact for policy and action: Postpartum depression is a global health issue, and there is an urgent need for interventions to promote respectful maternity care.

Instrument to evaluate the perception of abuse and/or disrespectful treatment during childbirth: A validation study.

AIM: To design and validate a tool to assess a woman's perception of whether she has experienced a situation of abuse or disrespect during childbirth attendance: "Childbirth Abuse and Respect Evaluation-Maternal Questionnaire" (CARE-MQ). METHODS: Multidisciplinary panel of experts (gynecologists, midwives, mothers) participated in creating CARE-MQ. A cross-sectional study was carried out on 901 Spanish women who had given birth between 1 and 3 months before to determine psychometric characteristics. Finally, an exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and a convergent validity study were carried out with the Quality Questionnaire from the Patient's Perspective-Intrapartum (QPP-I), and a reliability study using internal consistency (Cronbach's α) and coefficient of intraclass correlation (CCI). FINDINGS: The KMO test gave a value of 0.935, and Bartlett's sphericity test was <0.001. The EFA identified four components ("Emotional Abuse", "Inadequate Professionalism", "Physical Abuse" y "Lost contact") that explained 55.16 % of variance. In the CFA, a good fit was observed for most of the evaluated indicators. CARE-MQ correlated negatively with QPP-I (Spearman's rho = -0.641, 95 % CI: -0.679, -0.600; p < 0.001) and was statistically associated with variables related to childbirth experience (p < 0.005) such as the use of a birth plan, use of regional analgesia, type of birth, episiotomy, presence of severe tears, skin-to-skin contact, length of hospital stay and postpartum surgical intervention. Cronbach's α value was 0.903. The ICC of absolute agreement after administering the questionnaire one week after was 0.927 (95 % CI: 0.85-0.97). CONCLUSIONS: CARE-MQ is a valid and reliable instrument to evaluate the perception of a woman regarding the situation of abuse and/or disrespect that she may have experienced during birth in a population of Spanish postpartum women.

Social support and elder mistreatment in Brazil: exploring relationships and moderating effects.

Prior literature has demonstrated a negative association between social support and elder mistreatment. Furthermore, social support may moderate the negative relationship between health-related indicators and elder mistreatment. This study is the first to investigate these assertions in Brazil using nationally representative data. We employ the 2019 National Health Survey and a series of binary logistic regressions. Overall, increased social support from stronger ties, like family and close friends, reduces the likelihood of elder mistreatment. However, increased participation in broader and more distant social networks and circles of sociability may increase the risk of mistreatment. Moreover, the negative relationship between health-related indicators and elder mistreatment is partially moderated by increased social support. While findings on other support dimensions vary, family support appears crucial in mitigating elder mistreatment. This study contributes by underscoring the intricate interplay of social support, health, and mistreatment, advocating for family-centered interventions to improve elder well-being in Brazil.

Prevalence and Characteristics of Medical Student Mistreatment in Lebanon.

Objective: This study aimed to determine the prevalence of medical student mistreatment in Lebanon, the framework of the incidents, and the extent of students' knowledge on mistreatment characteristics. Methods: This is a cross-sectional study conducted using an online-based survey among medical students who have performed clinical rotations in Lebanon. Results: Out of 300 respondents, 48.7% reported being subjected to mistreatment during clinical practice, which was significantly associated with gender, type of university, and family income. The two most common sources of mistreatment were patients and their families/friends (77.4%), and attending physicians (52.7%), followed by residents (49.3%). Students mostly chose to be passive and pacifying. Additionally, 64.7% of students stated they were not trained about the ideal way to handle these incidents. Conclusion: This study showed that medical student mistreatment is highly prevalent in Lebanon. It also highlighted the lack of proper education on mistreatment characteristics and the necessity for investigating its effects.

Raising Awareness of Mistreatment Policies and Reporting Procedures Using a Novel Medical Student Mobile Application.

BACKGROUND: Reports of mistreatment are an important first step to improving medical students' learning environment. Students may not report mistreatment due to a lack of awareness of institutional policies, reporting procedures, or for fear of reprisal. AIM: We sought to determine if a medical school cross-platform mobile application (app) could be used to improve students' awareness of mistreatment policies and procedures. SETTING AND PARTICIPANTS: Participants in this intervention included Drexel University College of Medicine (DUCOM) medical students, faculty, and Student Affairs Deans. PROGRAM DESCRIPTION: We created the DUCOMpass© app to make mistreatment policies and procedures more readily available and to ease mistreatment reporting for medical students. PROGRAM EVALUATION: To determine the efficacy of the app at raising mistreatment awareness, we analyzed our institutional Graduation Questionnaire data before and after the introduction of the app (from 2016 to 2023) as compared with the national average. We verified our students' self-reported data with app usage data. DISCUSSION: To our knowledge, this is the first instance of a medical school mobile app being implemented to successfully address medical student mistreatment awareness and reporting. We found that reaching students in a familiar and easily accessible mode(s) of communication is a catalyst for lasting change. NIH TRIAL REGISTRY: Not applicable.

Evidence of Horizontal Violence in Healthcare Settings: A Narrative Review.

In the professional realm, the healthcare sector stands out as one of the most susceptible to violence. One notable manifestation of this is violence among colleagues, commonly referred to as horizontal violence, which has garnered significant attention in recent times. To delve deeper into this phenomenon across various categories of healthcare professionals, a comprehensive search was conducted on PubMed, Scopus, and CINAHL, resulting in the inclusion of 13 articles. The findings of this narrative review illuminate how horizontal violence can manifest in both physical and psychological forms and how it often becomes normalized among the healthcare professionals who endure it. Particularly vulnerable to such occurrences are recent graduates and those with limited professional experience. Furthermore, it has been observed that horizontal violence has detrimental effects on the well-being of those subjected to it, as well as on the quality of patient care delivered. Considering preventive measures, numerous studies emphasize the pivotal role of effective departmental leadership in fostering a harmonious work environment. Despite the largely underreported nature of this phenomenon, the conclusions drawn in this study advocate for a deeper exploration of the dynamics surrounding horizontal violence, with the goal of devising targeted strategies to mitigate its occurrence.

Emergency department and hospital-based programs responding to elder mistreatment: developing consensus about an idea whose time has come.

Elder mistreatment is common, serious, and under-recognized, with Emergency Department and hospital clinical encounters offering a potential but currently unrealized opportunity to identify and help older adults experiencing mistreatment. Interdisciplinary emergency department and hospital-based response teams represent a promising care model to address this. This manuscript describes two such teams and introduces a special issue dedicated to this work.

Examining ethical issues that arise in providing ED/hospital care for patients experiencing elder mistreatment and approaches to address them.

Clinicians in the emergency department and hospital who treat patients experiencing elder mistreatment (EM) can expect to encounter challenging ethical dilemmas. Collaboration with ethics and EM consultation services offers teams an important opportunity to improve patient-centered outcomes and address value-based concerns when treating these patients. This article describes the role of a hospital clinical ethics consultation service and best practices for collaboration between ethics and EM consultation services. Illuminated via four case studies, the article presents several core ethical frameworks, including allowing patients the dignity of risk, considerations around a harm reduced discharge, involving abusers in surrogate decision making, and providers' experience of moral distress when dealing with patients experiencing EM. Increasing collaboration with ethics and elder mistreatment services can help teams more effectively respond to EM.

Influence of meaningfulness of work and leadership characteristics on customer-directed counterproductive work behavior resulting from customer mistreatment.

This study explored the impact of customer mistreatment on counterproductive work behavior (CWB) and the moderating role of supervisor responses (self-sacrificial and self-serving leadership) to clarify why customer-directed CWB occurs and how it can be reduced. A sample of 392 customer-facing employees in the USA completed measures assessing the meaningfulness of work and self-sacrificial and self-serving leadership experiences. The meaningfulness of work moderated the relationship between customer mistreatment and employee anger, and a three-way interaction was found between employee anger and self-sacrificial and self-serving leadership on customer-directed CWB. Implications for managing customer mistreatment and fostering meaningful work to promote employee well-being are discussed.

Evaluation of a culture change program to reduce unprofessional behaviours by hospital co-workers in Australian hospitals.

BACKGROUND: Unprofessional behaviours between healthcare workers are highly prevalent. Evaluations of large-scale culture change programs are rare resulting in limited evidence of intervention effectiveness. We conducted a multi-method evaluation of a professional accountability and culture change program "Ethos" implemented across eight Australian hospitals. The Ethos program incorporates training for staff in speaking-up; an online system for reporting co-worker behaviours; and a tiered accountability pathway, including peer-messengers who deliver feedback to staff for 'reflection' or 'recognition'. Here we report the final evaluation component which aimed to measure changes in the prevalence of unprofessional behaviours before and after Ethos. METHODS: A survey of staff (clinical and non-clinical) experiences of 26 unprofessional behaviours across five hospitals at baseline before (2018) and 2.5-3 years after (2021/2022) Ethos implementation. Five of the 26 behaviours were classified as 'extreme' (e.g., assault) and 21 as incivility/bullying (e.g., being spoken to rudely). Our analysis assessed changes in four dimensions: work-related bullying; person-related bullying; physical bullying and sexual harassment. Change in experience of incivility/bullying was compared using multivariable ordinal logistic regression. Change in extreme behaviours was assessed using multivariable binary logistic regression. All models were adjusted for respondent characteristics. RESULTS: In total, 3975 surveys were completed. Staff reporting frequent incivility/bullying significantly declined from 41.7% (n = 1064; 95% CI 39.7,43.9) at baseline to 35.5% (n = 505; 95% CI 32.8,38.3; χ2(1) = 14.3; P < 0.001) post-Ethos. The odds of experiencing incivility/bullying declined by 24% (adjusted odds ratio [aOR] 0.76; 95% CI 0.66,0.87; P < 0.001) and odds of experiencing extreme behaviours by 32% (aOR 0.68; 95% CI 0.54,0.85; P < 0.001) following Ethos. All four dimensions showed a reduction of 32-41% in prevalence post-Ethos. Non-clinical staff reported the greatest decrease in their experience of unprofessional behaviour (aOR 0.41; 95% CI 0.29, 0.61). Staff attitudes and reported skills to speak-up were significantly more positive at follow-up. Awareness of the program was high (82.1%; 95% CI 80.0, 84.0%); 33% of respondents had sent or received an Ethos message. CONCLUSION: The Ethos program was associated with significant reductions in the prevalence of reported unprofessional behaviours and improved capacity of hospital staff to speak-up. These results add to evidence that staff will actively engage with a system that supports informal feedback to co-workers about their behaviours and is facilitated by trained peer messengers.

Prevalence of Self-reported Domestic Elder Abuse and Its Relation with Personality Traits of Older People and Their Family Caregivers.

BACKGROUND: Elder abuse (EA) is a serious public health issue recognized as a healthcare priority. Personality traits can influence social behaviors. This study aimed to determine the prevalence of self-reported domestic EA and its relationship with personality traits of older people and their family caregivers. METHODS: A cross-sectional study was conducted in 2022. The research population included older people living in the urban community of the Lorestan Province (in the western region of Iran) selected by multistage cluster sampling. In general, 998 older people and their family caregivers were sampled. The data collection tool was a three-part questionnaire: a. demographic characteristics of the older people, b. questionnaire on the incidence of elder abuse, and c. short version of the NEO Five-Factor Inventory-Revised (NEO-FFI-R) for measuring the personality traits of the older people or family caregivers. The statistical software used was Stata 14. RESULTS: The present study reported that the prevalence of EA at home was 37.78%. In the present study, older age, female gender, unmarried/single status, lower education, unemployment, and rented house characteristics were predictors of EA. High agreeableness, high extroversion, and low neuroticism reduce conflict and tension in older people with their relatives and family, which appear to be protective factors against EA. CONCLUSION: Policymakers and health experts should prepare training and screening programs to consider these factors so that older people exposed to EA can be identified more quickly and early interventions can be used to improve their health status and increase their quality of life.

'It was horrible to watch, horrible to be a part of': Midwives' perspectives of obstetric violence.

BACKGROUND: Obstetric violence, including unconsented interventions, coercion and disrespect, violates human rights; impacting the physical and psychosocial health of women. The perspective and experience of midwives related to obstetric violence have been explored in low and middle-income countries, with limited research into the experience of midwives in high income nations. AIM: To explore Australian midwives' perspectives of obstetric violence. METHODS: Thematic analysis of qualitative in-depth interviews with 15 midwives experienced in supporting women during birth. Critical feminist theory underpinned each stage of the research. FINDINGS: Interviews with 15 Australian midwives from diverse care settings were analysed thematically. Four key themes were developed from the data: 'the operationalisation of obstetric violence', 'the impact of obstetric violence' 'the historical and situational context' and 'hope for the future'. Midwives considered entrenched patriarchal structures and gender inequity as fundamental to the occurrence of obstetric violence. This societal scaffold is intensified within health care systems where power imbalances facilitate maternal mistreatment through coercion and grooming women for compliance in the antenatal period. Fragmented care models expose women to mistreatment with continuity models being protective only to a point. Midwives experience their own trauma, as a result of what they have witnessed, and due to the lack of support they receive when advocating for women. CONCLUSIONS: Obstetric violence occurs in Australian maternity systems with unconsented interventions, overmedicalisation, coercion, and disrespect observed by midwives. Care-related trauma impacts on the mental health of midwives, raising workforce concerns for policy makers, consumer advocates and professional bodies.

Developing a model for providing feedback to reporters of elder abuse.

Lack of feedback about reports made to Adult Protective Services (APS) is an important barrier to elder mistreatment reporting. To better understand barriers and facilitators to APS-reporter communication, we conducted an environmental scan of state policies and practices. We gathered publicly available information from 52 states and territories on APS administrative structure, reporting, intake, investigation, and feedback processes; performed a secondary analysis of focus groups with Emergency Medical Services providers and APS staff; and interviewed 44 APS leaders in 24 states/territories. Results revealed variation in information-sharing with reporters. Qualitative analyses revealed three overarching themes related to whether, when, and how information is shared. Results were used to develop a model illustrating factors influencing APS decisions on sharing information. This model incorporates the type of reporter (professional or nonprofessional), their relationship with the APS client (brief or ongoing), and the potential risks and benefits of sharing information with the reporter.

Challenges to the implementation of a multi-level intervention to reduce mistreatment of women during childbirth in Iran: a qualitative study using the Consolidated Framework for Implementation Research.

BACKGROUND: Mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In response, we launched a comprehensive implementation research (IR) project to reduce mistreatment during childbirth and enhance positive birth experiences in birth facilities. This study identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). METHODS: An exploratory qualitative study, involving 30 in-depth interviews, was conducted between July 2022 and February 2023. Participants included a purposive sample of key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals) with sufficient knowledge, direct experience, and/or collaboration in the implementation of the studied interventions. Interviews were transcribed verbatim and coded using directed qualitative content analysis (CFIR constructs) in MAXQDA 18. RESULTS: The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability, design quality and packaging, cosmopolitanism; presence of birth companions: e.g., patient needs and resources, structural characteristics, culture); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority, access to knowledge and information, reflecting and evaluating); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief during childbirth guidelines: e.g., networks and communications, patient needs and resources, executing, reflecting and evaluating). CONCLUSIONS: This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth and highlights potential implications for policy makers and practitioners of maternal health programs. We encourage them to take the lessons learned from this study and revise their current programs and policies regarding the quality of maternity care by focusing on the identified challenges.

Evidence suggests that mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In this qualitative study, through 30 in-depth interviews with key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals), we identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR). The data were analyzed using directed content analysis and a deductive approach in MAXQDA 18 software. The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability; presence of birth companions: e.g., patient needs and resources); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief childbirth guidelines: e.g., networks and communications). This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth; and highlights potential implications for policy makers and practitioners of maternal health programs.

Role of Obstetric Violence and Patient Choice: Factors Associated With Episiotomy.

INTRODUCTION: In the United States, 1 in 6 women reports obstetric violence in the form of physical and verbal abuse, coercion, and lack of informed consent. Despite recommendations against routine episiotomy, its use in the United States remains notable and varies considerably. This study aimed to analyze the various forms of obstetric violence associated with undergoing an episiotomy and having a choice in undergoing an episiotomy. METHODS: Data from the cross-sectional Listening to Mothers in California survey were analyzed using weighted sample. Logistic regression models were conducted to compute adjusted odds ratios (aORs) and 95% CIs for undergoing episiotomy and having a choice in it. RESULTS: Overall, 21% of the respondents reported undergoing an episiotomy, and 75% of them reported not having a choice in undergoing this procedure. After adjusting for covariates, feeling pressured to induce labor (aOR, 1.31; 95% CI, 1.28-1.35) and to use an epidural analgesia (aOR, 1.82; 95% CI, 1.77-1.88) increased the odds of undergoing an episiotomy. Having a midwife during childbirth significantly reduced the odds of an episiotomy. Respondents who indicated being handled roughly by health care providers were 95% less likely to have a choice in receiving an episiotomy (aOR, 0.05; 95% CI, 0.04-0.06). DISCUSSION: This is the first study to examine other forms of obstetric violence as correlates of episiotomy and having a choice in it. Standardized institutional measures against obstetric violence, patients' ability to make autonomous decisions through informed consent, and engaging midwives could decrease medically unnecessary labor procedures and associated complications.