Power, autonomy, and the construction of the ‘difficult patient’ in the labor ward: Insights from maternal health providers in western Kenya and northern Ghana

Disrespect and abuse during childbirth are frequently justified by providers on the grounds that the woman was “difficult.” Although challenging patient-provider interactions have been recognized as a driver of poor maternity care, little is known about how providers construct the notion of the “difficult patient” or how they navigate these situations. We explored maternity care providers’ perspectives on factors that contribute to difficult situations during childbirth and on their responses to such encounters in Kenya and Ghana. We conducted 51 in-depth interviews with maternity care providers, including nurses, midwives, doctors, clinical officers, and support staff, in western Kenya (n = 31) and northern Ghana (n = 20). Interviews were audio-recorded, transcribed verbatim, and analyzed using codebook thematic analysis with a combination of deductive and inductive coding. Providers described difficult situations as arising from the interaction of patient, provider, and health system factors rather than from patient characteristics alone. Four themes contributed to these situations: patients’ attitudes, behavior, and psychological state; conflicting beliefs and preferences; encounters in which healthcare providers were patients; and challenging workplace conditions. Providers responded by seeking assistance from colleagues or family members, adapting communication strategies, enforcing clinical instructions, temporarily disengaging from difficult interactions, or respecting patients’ wishes while documenting refusals or referring patients when necessary. While some responses aligned with principles of person-centered care, others reflected tensions between respecting patient autonomy and maintaining provider authority under resource-constrained conditions. Our findings challenge the notion of the inherently “difficult patient” by demonstrating that challenging maternity care encounters are socially and structurally produced through interactions among women, providers, and the health system. Interventions to improve respectful maternity care should address not only provider communication and interpersonal skills but also the organizational conditions and power dynamics that shape patient-provider interactions during childbirth.