There is growing evidence from Nigeria and around the world that women who deliver their babies in health facilities can experience mistreatment. In our study, we describe how frequently this happens in Gombe state,
north-eastern Nigeria, and what type of mistreatments women experience. Using a questionnaire, we interviewed consenting women as they left the facility after birth and asked them about events that occurred during their labour and delivery, and their perception of the care that health workers provided. In addition, through in-depth interviews and focus group discussions, we talked to women with young infants about mistreatment at birth and asked them to try to explain their experiences to us. At least one type of mistreatment was reported by 66% of the women. About 50% of others experienced mistreatment due to poor health system conditions and constraints, for example staff shortages or staff not having the commodities they needed to provide care. And 46% experienced mistreatment related to having poor rapport with the provider, for example being denied a birth companion, examined without permission or not allowed to give birth in their preferred position. Both health system constraints and poor health worker behaviours limit efforts to increase coverage of institutional delivery.  Immediate and sustained attention to the quality of care as it pertains to the experience of users is needed.