Background
According to the World Health Organization, respectful maternity care is “care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth.” [8] Examples of respectful care include, but are not limited to, allowing women to make decisions about their care such as whether they would like a companion, asking permission to conduct procedures and explaining those procedures to women, and ensuring women know their rights. The Respectful Maternity Care Charter outlines rights of childbearing women [9], which respectful care upholds. |
Methods
Setting and participants
Theoretical framework
Materials and processes
Analysis
Results
We conducted 46 individual interviews and nine multi-hour observations at health facilities (see Table 1)
Characteristics Participant type | Number of participants | Respondent characteristics |
---|---|---|
Total | 46 | |
Provider | 17 | Interview locations: |
Central hospital: 3 | ||
Urban clinic: 11 | ||
Rural clinic: 3 | ||
Gender of respondents: | ||
15 female | ||
2 male | ||
Midwife supervisor or mentor | 3 | Interview locations: |
Urban clinic: 1 | ||
Rural clinic: 2 | ||
Gender of respondents: | ||
1 female | ||
2 male | ||
SMAG volunteer | 7 | Interview locations: |
Urban clinic: 4 | ||
Rural clinic: 3 | ||
Gender of respondents: | ||
5 female | ||
2 male | ||
Client | 15 | Interview locations: |
Urban clinic: 4 | ||
Rural clinic: 3 | ||
Community setting: 8 | ||
Gender of respondents: | ||
15 female | ||
Birth companion | 4 | Interview locations: |
Community setting (urban): 4 | ||
Gender of respondents: | ||
4 female |
Barriers to Respectful Maternity Care | Contextual Features | |||
---|---|---|---|---|
Individual level | Interpersonal level | Organizational level | Community level | |
▪ Providers do not consider the decision to provide respectful care because they already believe they are providing respectful care or what they are expected to do | ▪ Provider had a painful delivery and has attended many painful deliveries ▪ With experience provider has developed a “feel” for how care is provided | ▪ Supervision and feedback focused on clinical treatment and health risks | ▪ Training is focused on clinical treatment ▪ Clinical algorithms and guidelines, including visual cues in the facility do not provide clear guidelines for good care | ▪ Pain is seen as a natural birth experience |
▪ Providers do not consider the decision to provide respectful care explicitly since abuse and violence are normalized and therefore the default | ▪ Provider experienced violence as a child as a form of discipline | ▪ Actions of other providers reinforce the perception that maintaining control is paramount | ▪ Training emphasizes need for rigid, forcefully delivered commands and interventions | |
▪ Providers decide not to provide respectful care since they believe they do not need to provide it | ▪ Provider has never interacted with the client before delivery and client behaves erratically or does not follow instructions | ▪ No serious consequences to providers who engage in disrespectful or abusive behavior | ▪ Client appears to be low income or low status | |
▪ Providers decide not to provide respectful care consistently since they believe that the costs of providing it outweigh the gains | ▪ Maternal or infant death results in an audit ▪ No salient information or feedback on the impact of respectful or disrespectful care on health outcomes | |||
▪ Providers change their mind on providing respectful care when they believe that disrespectful care will assist their objectives | ▪ Client does not follow instructions of provider |