The mistreatment of women during maternity care and its association with the maternal continuum of care in health facilities.

BACKGROUND: Mistreatment of childbearing women continues despite global attention to respectful care. In Ethiopia, although there have been reports of mistreatment of women during maternity care, the influence of this mistreatment on the continuum of maternity care remains unclear. In this paper, we report the prevalence of mistreatment of women from various dimensions, factors related to mistreatment and also its association to the continuum of maternity care in health facilities. METHODS: We conducted an institution-based cross-sectional survey among women who gave birth within three months before the data collection period in Western Ethiopia. A total of 760 women participated in a survey conducted face-to-face at five health facilities during child immunization visits. Using a validated survey tool, we assessed mistreatment in four categories and employed a mixed-effects logistic regression model to identify its predictors and its association with the continuum of maternity care, presenting results as adjusted odds ratios (AORs) with their 95% confidence intervals (CIs). RESULTS: Over a third of women (37.4%) experienced interpersonal abuse, 29.9% received substandard care, 50.9% had poor interactions with healthcare providers, and 6.2% faced health system constraints. The odds of mistreatment were higher among women from the lowest economic status, gave birth vaginally and those who encountered complications during pregnancy or birth, while having a companion of choice during maternity care was associated to reduced odds of mistreatment by 42% (AOR = 0.58, 95% CI: [0.42-0.81]). Women who experienced physical abuse, verbal abuse, stigma, or discrimination during maternity care had a significantly reduced likelihood of completing the continuum of care, with their odds decreased by half compared to those who did not face such interpersonal abuse (AOR = 0.49, 95% CI: [0.29-0.83]). CONCLUSIONS: Mistreatment of women was found to be a pervasive problem that extends beyond labour and birth, it negatively affects upon maternal continuum of care. Addressing this issue requires an effort to prevent mistreatment through attitude and value transformation trainings. Such interventions should align with a system level actions, including enforcing respectful care as a competency, enhancing health centre functionality, improving the referral system, and influencing communities to demand respectful care.

Domestic and family violence and associated maternal and perinatal outcomes: A population-based retrospective cohort study.

BACKGROUND: Domestic family violence (DFV) is a global health concern affecting one in three women worldwide. Women are vulnerable to DFV throughout their life; however, pregnancy introduces an increased risk of experiencing DFV for millions of women and birthing people. METHODS: Routinely collected data from two hospitals in one local health district in New South Wales, Australia, were examined to determine the prevalence of DFV from 2010 to 2019. Demographics and outcome factors were compared by a reported history of DFV. Multivariable logistic regression was used to assess for predictors of DFV and to assess DFV as a predictor of adverse maternal and perinatal outcomes. RESULTS: One percent of women (538/52,469) experienced DFV in the past year. Women experiencing domestic violence were more likely to be younger and have previous children, and had higher Edinburgh Depression Scores. These women were more likely to experience stillbirth (1.5% vs. 0.6%, p = 0.005). Maternal age < 25 years, cigarette smoking, alcohol use in pregnancy, mental health issues, and place of birth were associated with a recent history of DFV after adjusting for confounders. Recent DFV was associated with preterm birth and mental health issues but was not associated with admission to the neonatal nursery, small-for-gestational-age birthweight, or caesarean section after adjusting for confounders. CONCLUSION: There was a relationship between DFV and poorer health outcomes for both women and their babies. This study highlighted that stillbirth is high among the population of women who experience DFV when compared to women who do not experience DFV.

The roles of multi-component interventions in reducing mistreatment of women and enhancing respectful maternity care: a systematic review.

BACKGROUND: Despite recognition of the adverse impacts of the mistreatment of women during pregnancy, labour and birth, there remains limited evidence on interventions that could reduce mistreatment and build a culture of respectful maternity care (RMC) in health facilities. The sustainability of effective individual interventions and their adaptability to various global contexts remain uncertain. In this systematic review, we aimed to synthesise the best available evidence that has been shown to be effective in reducing the mistreatment of women and/or enhancing RMC during women's maternity care in health facilities. METHODS: We searched the online databases PubMed, CINAHL, EBSCO Nursing/Academic Edition, Embase, African Journals Online (AJOL), Scopus, Web of Science, and grey literature using predetermined search strategies. We included cluster randomized controlled trials (RCTs) and pre-and-post observational studies and appraised them using JBI critical appraisal checklists. The findings were synthesised narratively without conducting a meta-analysis. The certainty of evidence was assessed using GRADE criteria. RESULTS: From the 1493 identified records, 11 studies from six sub-Sahara African countries and one study from India were included: three cluster RCTs and nine pre- and post-studies. We identified diverse interventions implemented via various approaches including individual health care providers, health systems, and policy amendments. Moderate certainty evidence from two cluster RCTs and four pre- and post-studies suggests that multi-component interventions can reduce the odds of mistreatment that women may experience in health facilities, with odds of reduction ranging from 18 per cent to 66 per cent. Similarly, women's perceptions of maternity care as respectful increased in moderate certainty evidence from two cluster RCTs and five pre- and post-studies with reported increases ranging from 5 per cent to 50 per cent. CONCLUSIONS: Multi-component interventions that address attitudes and behaviors of health care providers, motivate staff, engage the local community, and alleviate health facility and system constraints have been found to effectively reduce mistreatment of women and/or increase respectful maternity care. Such interventions which go beyond a single focus like staff training appear to be more likely to bring about change. Therefore, future interventions should consider diverse approaches that incorporate these components to improve maternal care.

Australian women's perspectives of routine enquiry into domestic violence before and after birth.

BACKGROUND: Peripartum women are vulnerable to experiencing intimate partner violence (IPV). Interactions with health practitioners during maternity care provide a unique opportunity to detect and respond to women who are experiencing IPV. The aim of this study was to explore women's experiences of IPV screening at an Australian maternity service. METHODS: Qualitative methodology was used in this cross-sectional study. In-depth semi-structured interviews were conducted with women with IPV who attended an Australian maternity service. Thematic analysis was used to identify codes and themes. RESULTS: The nine women expressed three major themes, and six sub-themes, surrounding clinician approaches (communication and support, asking about IPV, and following disclosure), system considerations (fear of child safety involvement, continuity of care, and environmental considerations), and education. All participants supported screening and highlighted beneficial or detrimental approaches to screening and care, and recommendations for improvement. CONCLUSION: This research points to the benefit of trauma-informed frameworks in hospitals to support women experiencing IPV.

Improving domestic violence screening practices in the emergency department: an Australian perspective.

INTRODUCTION: Domestic violence (DV) is a major cause of morbidity worldwide. The ED is a location recommended for opportunistic screening. However, screening within EDs remains irregular. OBJECTIVE: To examine intrinsic and extrinsic barriers to routine screening in Australian EDs, while describing actions taken after identification of DV. METHODS: Emergency clinicians at nine public hospitals participated in an anonymous online survey. Factor analysis was performed to identify principal components around attitudes and beliefs towards screening. RESULTS: In total, 496 emergency clinicians participated. Universal screening was uncommon; less than 2% of respondents reported screening all adults or all women. Although willing, nearly half (45%) reported not knowing how to screen. High patient load and no single rooms were 'very or severely limiting' for 88% of respondents, respectively, while 24/7 social work and interpreter services, and online/written DV protocols were top enablers. Factor analysis identified four distinct intrinsic belief components: (1) screening is not futile and could be done in ED, (2) screening will not cause harm, (3) there is a duty to screen and (4) I am willing to screen. CONCLUSION: This study describes a culture of Queensland ED clinicians that believe DV screening in ED is important and interventions are effective. Most ED clinicians are willing to screen. In this setting, availability of social work and interpreter services are important mitigating resources. Clinician education focusing on duty to screen, coupled with a built-in screening tool, and e-links to a local management protocol may improve the uptake of screening and subsequently increase detection.

Self-efficacy and social support as mediators of mental health among abused women.

Supportive counseling and facilitated referrals to support organizations have shown positive effects on mental health and coping with domestic and family violence. However, the reasons why and how such effects are significant remain unknown. The current paper used data from a randomized controlled trial of a psychosocial intervention implemented in Nepal among 140 abused pregnant women. The hypothesized mediating effects of self-efficacy and social support on mental health and quality of life of abused pregnant women were tested using serial mediation analyses. Significance of parameter estimates and bias-corrected 95% confidence intervals (CIs) for the indirect effects were generated using bootstrapping. The postintervention changes in self-efficacy and social support were found to have significant mediating effects on the relationship between the intervention and changes in both mental health and quality of life of participants post intervention. The positive effects on outcomes were seen at follow-up as well, though to a lesser extent. Further interventions should focus on enhancing abused women's self-efficacy and social support to ensure their positive mental health and better lives.

Cost of intimate partner violence during pregnancy and postpartum to health services: a data linkage study in Queensland, Australia.

To quantify health service costs of intimate partner violence (IPV) during pregnancy and postpartum; and to compare health service costs between women who reported IPV, versus women who did not report IPV. This was a cohort study using linked data for a publicly funded Australian tertiary hospital maternity service. Participants included all women accessing antenatal services between August 2016 and August 2018. Routinely collected IPV data were linked to women's admitted, non-admitted, emergency department, perinatal, and costing data from 6 months prior to reporting IPV through to 12 months post-birth. Of the 9889 women receiving maternity care, 280 (2.9%) reported some form of IPV with 72 (24.8%) referred to support. Women who reported IPV generated higher mean total costs than women not reporting IPV ($12,772 vs $10,166, respectively). Between-group differences were significant after adjusting for demographic and clinical factors (cost ratio 1.24, 95% CI: 1.15-1.34). There were no significant differences in mean total costs for babies where IPV was and was not reported ($4971 vs $5340, respectively). IPV is costly for health services. However, greater research is needed to comprehensively estimate the long-term health service costs associated with IPV. Furthermore, the limitations associated with routinely collected IPV data suggest that standardised screening practices and innovative data linkage and modelling approaches are required to collect data that truly represents the burden and costs associated with IPV.

Australian hospital staff perceptions of barriers and enablers of domestic and family violence screening and response.

BACKGROUND: Hospital presentations provide unique opportunities to detect DFV. However, up to 70% of women experiencing Domestic and Family Violence (DFV) go undetected by hospital staff. While routine DFV screening is internationally encouraged, there is still much debate surrounding its implementation. The aim of the study was to determine staff perceptions of barriers and enablers of DFV screening and response. METHODS: A cross-sectional survey was conducted at a tertiary level public hospital and health service. Health care staff in allied health, maternity and mental health divisions (n = 615) were invited to participate by email and through team meetings. 172 responses were analysed. RESULTS: Less than a third of respondents reported routinely asking patients about DFV, with 34.9% reporting they did not have sufficient training to assist with DFV. Increased levels of training were positively correlated with screening practices, preparedness and knowledge. Major barriers were presence of partner and language barriers, while written protocols and supportive work environment were the principal enablers of screening. CONCLUSION: Staff generally believed that routine screening was important and should encompass all forms of abuse. Many felt ill-equipped to ask about or manage disclosure of DFV. More training improves staff capacity for DFV detection and response, and written guidelines should be made available to all staff.

Birth outcomes in a Swedish population of women reporting a history of violence including domestic violence during pregnancy: a longitudinal cohort study.

BACKGROUND: Victimisation of women is encountered in all countries across the world, it damages the mental and physical health of women. During pregnancy and the postpartum period, women are at a greater risk of experiencing violence from an intimate partner. The aim of this study was to explore childbirth outcomes in a Swedish population of women reporting a history of violence including domestic violence during pregnancy. METHODS: A longitudinal cohort design was used. In total, 1939 pregnant women ≥18 years were recruited to answer two questionnaires, both questionnaires were administered in the early and late stages of their pregnancy. The available dataset included birth records of 1694 mothers who gave birth between June 2012 and April 2014. Statistical analyses included descriptive statistics, T-test and bivariate logistic regression. RESULTS: Of 1694 mothers 38.7% (n = 656) reported a history of violence and 2% (n = 34) also experienced domestic violence during pregnancy. Women who were single, living apart from their partner, unemployed, smoked and faced financial distress were at a higher risk of experiencing violence (p = 0.001). They also had significant low scores on the SOC-scale and high EDS-scores ≥13 (p = 0.001) when compared to women without a history of violence (p = 0.001). Having a history of violence increased the woman's risk of undergoing a caesarean section (OR 1.33, 95% CI 1.02-1.70). A history of emotional abuse also significantly increased the risk of having a caesarean section irrespective of whether it was a planned or an emergency caesarean section (OR 1.50, 95% CI 1.09-2.06). Infants born to a mother who reported a history of violence, were at significant risk of being born premature < 37 weeks of gestation compared to infants born by mothers with no history of violence (p = 0,049). CONCLUSIONS: A history of violence and/or exclusively a history of emotional abuse has a negative impact on childbirth outcomes including caesarean section and premature birth. Therefore, early identification of a history of or ongoing violence is crucial to provide women with extra support which may have positive impact on her birth outcomes.

The role of nurses and midwives in the provision of abortion care: A scoping review.

AIMS AND OBJECTIVES: To define the role and scope of the nurse and midwife within the global context of abortion. BACKGROUND: An estimated 56 million women seek abortions each year; nurses and midwives are commonly involved in their care (Singh et al., 2018, https://www.guttmacher.org/sites/default/files/report_pdf/abortion-worldwide-2017.pdf). As new models of abortion care emerge, there is a pressing need to develop a baseline understanding of the role and scope of nurses and midwives who care for women seeking abortions. DESIGN: The review design was Arksey and O'Malley's five-stage methodological framework. The review follows the PRISMA-ScR checklist. METHODS: MEDLINE, CINAHL, Scopus and ScienceDirect were used to identify original research, commentaries and reports, published between 2008-2019, from which we selected 74 publications reporting on the nursing or midwifery role in abortion care. RESULTS: Nurses and midwives provide abortion care in a variety of practice. Three themes emerged from the literature: the regulated role; providing psychosocial care; and the expanding scope of practice. CONCLUSIONS: The literature on nursing and midwifery practice in abortion care is broad. Abortion-related practices are potentially over-regulated. Appropriately trained nurses and midwives can provide abortions as safely as physicians. The preparation of nurses and midwives to provide abortion care requires further research. Also, healthcare organisations should explore person-centred models of abortion care. RELEVANCE TO CLINICAL PRACTICE: Abortion care is a common procedure performed across many healthcare settings. Nurses and midwives provide technical and psychosocial care to women who seek abortions. Governments and regulatory bodies could safely extend their scope of practice to increase women's access to safe abortions. Introduction of education programmes, as well as embedding practice in person-centred models of care, may improve outcomes for women seeking abortions.

Exploring the influence of psychosocial factors on exclusive breastfeeding in Bangladesh.

Exclusive breastfeeding is a proven benefit for both mothers and infants and is, therefore, an important public health priority. Intimate partner violence (IPV) is regarded as one of the potential psychosocial risk factors that may negatively affect exclusive breastfeeding (EBF). This study aimed to explore the influence of psychosocial factors including IPV on EBF. Cross-sectional survey data was collected from October 2015 to January 2016 in Chandpur District of Bangladesh from 426 married women, aged 15-49 years, who had at least one child 6 months of age or younger. Multivariate logistic regression models were used in order to investigate whether women who experienced IPV after childbirth, as well as other risk factors such as postpartum depression (PPD) and childhood sexual abuse, were more likely to face difficulties with EBF compared with women who had not experienced these same risk factors. Whilst the initiation rate of breastfeeding was 99.3%, at the time of the woman's interview, the overall EBF rate had fallen to 43.7%. Based on the adjusted model, women who experienced physical IPV (AOR 0.17, 95% CI [0.07, 0.40]) and psychological IPV (AOR 0.51, 95% CI [0.26, 1.00]) after childbirth and women who reported childhood sexual abuse (AOR 0.32, 95% CI [0.13, 0.80]) and PPD (AOR 0.20, 95% CI [0.09, 0.44]) were significantly less likely to exclusively breastfeed their infants than those who had not reported these experiences. Moreover, women with an intended pregnancy and high social support exhibited a higher likelihood of EBF. Our results suggest that preventing or reducing the occurrence of physical IPV, PPD and childhood sexual abuse may improve the EBF duration. Support from family members can assist in this process.

Intimate partner violence and pregnancy intentions: a qualitative study.

AIM AND OBJECTIVE: In this qualitative study, we explored women's pregnancy intentions and experiences of intimate partner violence before, during and after pregnancy. BACKGROUND: Unintended pregnancies in the context of intimate partner violence can have serious health, social and economic consequences for women and their children. DESIGN: Feminist and phenomenological philosophies underpinned the study to gain a richer understanding of women's experiences. METHODS: Eleven women who had been pregnant in the previous two years were recruited from community-based women's refuges in one region of the UK. Of the 11 women, eight had unplanned pregnancies, two reported being coerced into early motherhood, and only one woman had purposively planned her pregnancy. Multiple in-depth interviews focused on participants' accounts of living with intimate partner violence. Experiential data analysis was used to identify, analyse and highlight themes. RESULTS: Three major themes were identified: men's control of contraception, partner's indiscriminate response to the pregnancy and women's mixed feelings about the pregnancy. Participants reported limited influence over their sexual relationship and birth control. Feelings of vulnerability about themselves and fear for their unborn babies' safety were intensified by their partners' continued violence during pregnancy. CONCLUSION: Women experiencing intimate partner violence were more likely to have an unintended pregnancy. This could be attributed to male dominance and fear, which impacts on a woman's ability to manage her birth control options. The women's initial excitement about their pregnancy diminished in the face of uncertainty and ongoing violence within their relationship. RELEVANCE TO CLINICAL PRACTICE: Women experiencing violence lack choice in relation to birth control options leading to unintended pregnancies. Interpreting the findings from the victim-perpetrator interactive spin theory of intimate partner violence provides a possible framework for midwives and nurses to better understand and respond to women's experiences of violence during pregnancy.

Factors associated with childbirth self-efficacy in Australian childbearing women.

BACKGROUND: Childbirth confidence is an important marker of women's coping abilities during labour and birth. This study investigated socio-demographic, obstetric and psychological factors affecting self-efficacy in childbearing women. METHOD: This paper presents a secondary analysis of data collected as part of the BELIEF study (Birth Emotions - Looking to Improve Expectant Fear). Women (n = 1410) were recruited during pregnancy (≤24 weeks gestation). The survey included socio-demographic details (such as age and partner support); obstetric details including parity, birth preference, and pain; and standardised psychological measures: CBSEI (Childbirth Self-efficacy Inventory), W-DEQ A (childbirth fear) and EPDS (depressive symptoms). Variables were tested against CBSEI first stage of labour sub-scales (outcome expectancy and self-efficacy expectancy) according to parity. RESULTS: CBSEI total mean score was 443 (SD = 112.2). CBSEI, W-DEQ, EPDS scores were highly correlated. Regardless of parity, women who reported low childbirth knowledge, who preferred a caesarean section, and had high W-DEQ and EPDS scores reported lower self-efficacy. There were no differences for nulliparous or multiparous women on outcome expectancy, but multiparous women had higher self-efficacy scores (p < .001). Multiparous women whose partner was unsupportive were more likely to report low self-efficacy expectancy (p < .05). Experiencing moderate pain in pregnancy was significantly associated with low self-efficacy expectancy in both parity groups, as well as low outcome expectancy in nulliparous women only. Fear correlated strongly with low childbirth self-efficacy. CONCLUSION: Few studies have investigated childbirth self-efficacy according to parity. Although multiparous women reported higher birth confidence significant obstetric and psychological differences were found. Addressing women's physical and emotional wellbeing and perceptions of the upcoming birth may highlight their level of self-efficacy for birth. TRIAL REGISTRATION: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17(th) May 2012.

Women's views and experiences of antenatal enquiry for domestic abuse during pregnancy.

OBJECTIVE: The aim of this study was to explore the acceptability of antenatal enquiry for domestic abuse from the perspective of women using maternity services. It also sought to understand the experiences of referral and support offered to women who had positively disclosed abuse. METHODS: A multimethod approach was adopted including quantitative and qualitative elements. The survey assessed women's views of the acceptability and impact of routine enquiry for domestic abuse. Interviews aimed, to understand the views and experiences of women who had positively disclosed abuse during their contact with maternity services. RESULTS: 94.4% of those surveyed felt comfortable with a midwife asking about abuse. 96.6% of the participants also believed it was appropriate for a midwife to ask and that midwives should be able to respond to positive disclosure. Interviewees subject to abuse during pregnancy were happy to be questioned, even though they did not always feel able to disclose immediately. CONCLUSION: Women had a positive view of antenatal enquiry for domestic abuse in healthcare settings and support its continuation. Women expect to be asked and that midwives can respond appropriately. Raising the issue creates a culture in which women are made aware of the impact of abuse and understand there are avenues of support even if she decides not to leave the relationship. Women may choose not to disclose about the abuse at the initial time of asking, for fear of their own safety but asking signifies that she can disclose about at a later contact.

Women's lived experiences of domestic violence during pregnancy (2).

This paper is a follow up paper to a study which explored women's experiences of domestic violence before, during and after pregnancy. Findings from this study suggested that women would like midwives to be able to recognise the signs of domestic violence and to be able to offer them an appropriate response and support. Midwives are well placed to recognise the signs of domestic violence and provide appropriate support. This paper addresses some of the challenges and dilemmas for midwives when identifying and supporting women who have experienced domestic violence and provides some key messages for midwifery practice.

Women's lived experiences of domestic violence during pregnancy (1).

This paper reports on a qualitative study, which explored women's experiences of domestic violence before, during and after pregnancy. During pregnancy the women were physically attacked, including blows and kicks to the pregnant abdomen; they were punched, slapped, kicked, bitten, pushed around, held by the throat and attempts at strangulation occurred for two of the women. The women were sexually abused, experienced enforced isolation and financial hardship. They experienced extreme psychological distress, including depression before, during and after pregnancy. Feelings of vulnerability about themselves and their unborn babies were intensified by their partners' continuing violence and abuse. The findings from this research will support midwives to recognise the warning signs of domestic violence and abuse during pregnancy and to be able to offer an appropriate response.

Iranian Immigrant Women's Experiences of Intimate Partner Violence: A Literature Review.

Immigrant and refugee women are vulnerable to experiencing intimate partner violence (IPV) due to a range of factors associated with immigration. This study aims to consolidate existing research concerning IPV among Iranian immigrant women and examine its impact on their lives. A comprehensive literature search for articles of any design published in the English language in the past 15 years was performed using Medline, Embase, CINAHL, International Bibliography of the Social Sciences (ProQuest) and PsycINFO databases. The topic of IPV among Iranian immigrant women has been underexplored in research, and only 11 studies were identified that met the inclusion criteria for this topic. The findings from these studies indicate that Iranian immigrant women have experienced different forms of IPV, with psychological IPV being prominent and replacing physical violence. These experiences have had adverse effects on the women's physical and mental health. The women's experiences of IPV were influenced by various cultural, religious, and individual factors. They predominantly sought informal help rather than accessing formal resources to address their situations. There is a need for rigorous studies to thoroughly investigate IPV among Iranian immigrant and refugee women. Such research is essential for establishing effective strategies that are culturally sensitive to reduce IPV incidents within this population. Moreover, it is essential to enhance IPV awareness among these women and ensure their access to formal resources that are proficient in addressing IPV. This comprehensive approach not only tackles the immediate issue but also fosters a safer environment and promotes long-term wellbeing within this community.

Health care providers' perspectives on the mistreatment towards women during maternity care: Do perceptions of the working environment and empathy level matter?

BACKGROUND: Mistreatment of women in maternity care violates human rights, erodes trust and disrupts the continuity of maternal healthcare services. Investigating Health Care Providers' (HCPs) perspectives is indispensable in uncovering drivers and designing targeted interventions. AIM: To identify the roles of HCPs' perceptions of the working environment and levels of empathy on the mistreatment of women during maternity care. METHODS: We conducted a self-administered survey among 148 maternal HCPs practising in ten health centres and four hospitals in the East Wollega Zone, Western Ethiopia, from June to September 2022. FINDINGS: Most providers reported seeing other HCPs mistreating women (93.2%), while three-fourths (75.7%) admitted it as their actions. Violation of privacy and confidentiality was the most frequently reported category of mistreatment (44.6%), followed by physical abuse (37.1%) and verbal abuse (35.8%). The likelihood of mistreating women was reduced by 65% (AOR=0.35, 95% CI: [0.14, 0.86]) among individuals with positive perceptions of their working environment compared to those with negative perceptions. A unit increase in providers' empathy also led to a five per cent decrease in mistreatment (AOR=0.95, 95% CI: [0.91, 0.98]. CONCLUSIONS: HCPs' perceptions of their working environment and enhanced empathy levels were associated with the reduction of the odds of mistreatment of women. While empathic care should be cultivated as a component of HCPs' competencies, efforts should be made to improve the conditions of the demanding health system to realise a resilient, motivated, competent, and compassionate workforce. The interplay between gender, profession, and mistreatment level requires further investigation.