Obstetric violence (OV) is defined as abuse perpetuated by healthcare workers toward expectant women in the course of the birthing process, mainly in the form of disrespect, dehumanisation, medication abuse and other forms of bodily harm (1). OV contribute to maternal mortality by influencing women's choice not to seek facility-based birth, even when they might have risk factors (2–4). In this essay, we will review the evidence on OV in Ghana and how introducing Midwife-led care (MLC) could offer cost-effective solutions to OV in Ghana.

This article adopts a perspective to critically explore OV in Ghana and MLC as an approach to promote respectful and equitable maternity care. It does not generate primary data; instead, it synthesises and interprets existing evidence to inform policy and practice. Evidence was drawn from peer-reviewed qualitative and quantitative studies, systematic reviews, and policy documents from authoritative bodies such as the World Health Organisation (WHO) and the International Confederation of Midwives (ICM). Themes were organised and reported under clearly defined subheadings, including forms of obstetric violence, systemic and relational drivers, consequences for women's wellbeing and care-seeking, and mechanisms through which MLC may mitigate mistreatment during childbirth, and the effectiveness of MLC models, mainly in low- and middle-income countries and the Ghanaian context. The analysis focused on how continuity of care, women's autonomy, respectful communication, and culturally responsive practice—core features of MLC—may help reduce OV. Global evidence was interpreted alongside context-specific data from Ghana to enhance relevance for national health systems and maternal health policy.

The maternal mortality rate in Ghana is estimated at 234 deaths per 100,000 births (44), however, per the WHO country-specific target, Ghana needs to meet a target of less than 140 deaths per 100,000 (45–47) births to achieve Agenda 2030 (48). This is among the highest in LMICs according to the Ghana Health Service (GHS) (49). Ghana has invested in various strategies to reduce maternal mortality, including life-saving skills training, Community-based Health Planning and Services (CHPS), free maternity care, targeted antenatal services, the national health insurance scheme, etc. (50, 51). However, despite these efforts, the country did not meet Millennium Development Goal 5. The proportion of skilled birth deliveries in Ghana ranges from 54% to 63%, contrasting with the higher percentage of women (97%) who avail themselves of antenatal care services (10). This discrepancy suggests a significant number of Ghanaian women opt for home births under the care of unskilled birth attendants, potentially contributing to the increased rate of maternal deaths in the country.

Maya et al. (11) investigated the prevalence of OV and reported that the primary forms of mistreatment identified encompass verbal and physical abuse, as well as abandonment and insufficient support during the second stage of labour, particularly among adolescent mothers. Furthermore, slapping and pinching were considered acceptable methods to “correct” disobedient behaviour and encourage pushing (11). Consequently, many women expressed a reluctance to choose health facilities for future childbirth experiences, either based on their encounters with mistreatment or upon learning about mistreatment experiences from other women (11). Again, 65.1% of HIV-negative women experienced OV, slightly higher than 61% observed in HIV-positive women (52). These findings indicate that OV is a major concern in Ghana, irrespective of the status of the woman. In the Northern Region of Ghana, Moyer and her colleagues reported physical abuse (hitting women in labour, slapping, and kicking), verbal abuse (shouting, insulting, and speaking harshly, use of inappropriate words), neglect, discrimination based on the poverty level of the women, non-conformity to traditional customs during surrounding childbirth (preventing women from assuming a squatting position during labour and prohibiting women from retaining the placenta after childbirth) as the most common form of OV (20).

Dzomeku et al. (53) revealed that OV was pervasive in their qualitative study in two regions from the perspective of midwives. The study found that delivering insufficient care, neglecting patient-centred approaches, verbal maltreatment (insulting and shouting at childbearing women), bodily harm (hitting, whipping, and striking of pregnant women), and psychological mistreatment (disregarding, abandoning, delivering care that lacks a person-centred approach) were common. Again, from the perspective of midwifery students, Rominski et al. (54) reported justification of OV to include overwork, lack of resources, the culture of blaming midwives for maternal mortality, and disrespect towards midwives as causes of obstetric violence. Similarly, lack of skilled midwives, inadequate resources, competence of healthcare workers, and hygienic conditions at the hospital were the findings of a study in the Volta region (13). In Ghana, inadequate wage coerces some midwives to engage in trading and informal extortion, such as selling diapers, water, or clothing, which can result in neglect, discrimination, partiality, and even the detention of women unable to pay for items (55). A midwife-to-patient ratio of 1:560 in Ghana aggravates staff shortages and heavy workloads, contributing to the mistreatment of women (55). Additionally, the health system's hierarchical structure positions doctors and inflexible protocols as the definitive authority, subordinating midwives despite their specialised training. This marginalisation often motivates midwives to assert power over women, occasionally through bullying and offensive practices (56). Lately, Yalley (21) recounted that OV was common within health care and a routine. Midwives viewed OV as a delivery strategy and a form of help to the client. Shouting, forced medical care, stigmatisation, non-consented care, denial of birth companions, and denial of preferred birth Position were not uncommon (21). However, a study in Ghana on midwife-led obstetric triage training concluded that it enhances knowledge and practice, tackles the third delay and decreases avertible pregnancy-related deaths (57). Again, from LMICs' perspectives, MLC decreased both maternal and neonatal death (58). Moreover, managing OV among mothers is important to reduce the effects on women. This can result in better care, good interpersonal relationships, and positive outcomes of pregnancy (19). Therefore, replicating similar evidence in Ghana will help combat rampant OV in maternity wards nationwide.

Opposition from obstetricians is likely to increase if midwives are given autonomy to manage uncomplicated pregnancies. Therefore, it is essential to engage stakeholders and present evidence-based outcomes demonstrating the benefits of midwife-led care. Additionally, subsidising fees for continuing professional development and providing e-learning platforms will enable midwives in remote and underserved areas to enhance their skills. Moreover, the Ghanaian government should provide sufficient funds to help establish midwifery units. Furthermore, non-cooperation among disciplines could contribute to OV. Yet, collaboration strengthens interpersonal relationships, fosters trust, and provides access to varied competencies within an organisation (60). Adopting a collaborative care model can therefore reduce strict hierarchies, promote reciprocal respect among healthcare providers, and enhance teamwork and collective accountability (56).

Although OV and maltreatment of women during childbirth are universal phenomena, the prevalence in Ghana is high. However, Midwife-led care (MLC) is valid and evidence-based, proven effective in multiple LMICs. It directly targets determinants of obstetric violence—disrespect, poor communication, and lack of autonomy. In Ghana, implementation is feasible but requires system readiness and stakeholder engagement.