Transforming intrapartum care: Respectful maternity care

Exposure to disrespectful maternity care and perceptions of respectful maternity care among nursing and midwifery pre-registration students in China: A national cross-sectional study

AIMS

To 1) determine the prevalence and types of disrespectful maternity care witnessed by students; 2) describe students' perceptions of respectful maternity care and associated factors; and 3) investigate whether witnessing disrespectful care influences their perceptions of respectful maternity care.

BACKGROUND

Limited evidence exists about nursing and midwifery students' perceptions of respectful maternity care and prevalence of disrespectful maternity care in China. Understanding students' perceptions can inform pre-registration curricula and clinical practice programs, promoting the implementation of respectful maternity care.

DESIGN

An exploratory national online survey was conducted.

METHODS

Data were analysed using bivariate analysis and multi-factor analysis of variance.

RESULTS

Among 733 students, positive perceptions towards respectful maternity care were common. Approximately one-fifth witnessed disrespect, with physical violence, lack of communication and untimely care most frequently reported. A better understanding of respectful maternity care was associated with female students of Han ethnicity, majoring in midwifery, undertaking a longer internship/practicum and reporting fewer instances of observed disrespect. Although students reported positive perceptions of respectful maternity care, inadequate understanding was evident. Incorporating relevant content about respectful care into the curriculum is suggested. Reducing students' exposure to disrespectful maternity care may ensure that certain forms of disrespect or abuse do not become normalized among students. This requires system-level efforts to create a safe and supportive working environment for maternity health providers.

CONCLUSION

To promote respectful maternity care in China, system-level changes are warranted. Respectful maternity care needs to be essential content in pre-registration midwifery and nursing curricula. Encouraging students to identify poor practice and discuss good practice in a safe learning environment is warranted.

Healthcare providers' perspectives on sustaining respectful maternity care appreciated by mothers in five hospitals of Rwanda

BACKGROUND

Childbirth reserves respect, as emphasized by the World Health Organization in 2018, and the focus towards the need for positive, dignified delivery experiences has become an integral aspect of Respectful Maternity Care (RMC). It is a known fact that RMC is pivotal for favourable birth outcomes and contributes to the satisfaction of maternity care. The absence of RMC negatively affects women's and newborns' rights. The study aimed to explore healthcare providers' perspectives on sustaining RMC actions that mothers previously reported.

METHODOLOGY

This study was conducted in five hospitals in the Eastern province of Rwanda, involving 5 Focus Group Discussions (FGDs) with midwives and nurses. For interviews, we purposively selected 5-unit managers and five physicians. Additionally, 40 midwives and nurses were recruited for the FGDs. The research utilized the Dream phase of Appreciative Inquiry (AI) for interviews and Focus Groups. Data collection aimed to gain insights into Healthcare Providers' perceptions of how RMC is provided and how to establish and sustain RMC in Rwandan health facilities. Nvivo 12 was employed for organizing codes and creating a codebook, and thematic analysis was applied.

RESULTS

Four themes with sub-themes emerged. Namely, 1) Women-centered care, with Compassionate care, Privacy and confidentiality maintenance, Information provision and Liberty in decision making, Effective communication, Family involvement, Cleanliness, and Equality care. 2) Professionalism compliance with Motivated staff, Teamwork, Continuous development, Quality work provision, and Community trust. 3) RMC encounters 4) RMC sustenance.

CONCLUSION AND RECOMMENDATIONS

The continuous pursuit of high RMC standards in Rwanda involves improving childbirth experiences through utilizing existing resources, ongoing improvement, and sustaining achievements. Key recommended actions in this study for sustaining RMC encompass promoting women-centred care, enhancing healthcare provider attitudes, ensuring professionalism, building community trust, maintaining conducive health facility environments, and involving leadership.

Facilitating positive birth experience when preferences are not met: A qualitative analysis

INTRODUCTION

High-quality health systems rely on care that centers on patient preferences. Realization of patient preferences can improve the birth experience. However, in the dynamic setting of birth, birth preferences can diverge from what is medically indicated. Through studying women and birthing peoples' experiences of unplanned labor procedures, we aimed to identify ways in which practitioners can support women and birthing people through unexpected or unwanted aspects of their delivery. Specifically, we focused on labor induction.

METHODS

In one large US academic center, women and birthing people participated in prenatal and postpartum surveys regarding their desires, expectations, and experiences of labor induction. From April to November 2021, participants were eligible if they showed discordance between having labor induction and whether it was initially wanted or expected. Interviews focused on attitudes toward birth preferences and outcomes, with attention to discordances. We analyzed interviews through a modified grounded theory approach.

RESULTS

Of 22 participants, our sample was predominantly white (91%). Participants in this sample reported discordance between wanting and experiencing (73%) and/or expecting and experiencing (54%) an induction. We identified two themes: "Discordance without mitigation is perceived as a negative experience" and "Practitioner interaction can buffer against negative experience" which includes three ways in which participants prefer support in instances of discordance: preparation, communication, and care and comfort. These methods of support foster patient autonomy and can lead to positive patient experiences.

CONCLUSIONS

While medical systems should work to support patient preferences, our results suggest that patients can still have positive birth experiences, even when preferences are not fulfilled. Early practitioner preparation, positive communication, and responsive care and comfort may help to improve patient birth experience when challenges arise.

Factors associated with respectful maternity care and influence of HIV status among women giving birth in Kilimanjaro, Tanzania

BACKGROUND

Respectful maternity care (RMC) is a rights-based approach to childbirth that centers the dignity, autonomy, and well-being of birthing women. This study aimed to examine factors associated with RMC among women giving birth in Tanzania and to examine whether HIV status was associated with self-reported RMC.

METHODS

We enrolled 229 postpartum women in six clinics in the Kilimanjaro Region; of them, 103 were living with HIV. Participants completed a survey within 48 h after birth before being discharged. RMC was measured using a 30-item scale with three subscales (dignity and respect; supportive care; communication and autonomy), each standardized from 0 to 100. Univariable and multivariable regression models examined factors associated with RMC.

RESULTS

The median score of the full RMC score was 74, differing slightly by subscale: 83 for dignity and respect, 76 for supportive care, and 67 for communication and autonomy. RMC did not differ by HIV status (median 67.0 vs. 67.0, p = 0.89). In multivariable linear regression, women who would not recommend the birth facility to their friends and who did not receive breastfeeding education had significantly lower RMC scores on the full RMC scale. In the dignity and respect subscale, variables associated with significantly lower RMC scores were not being able to read and write, delivering in a public facility, and delivering vaginally.

CONCLUSIONS

Although self-reported RMC was generally high, we identified areas for improvement. Practitioners need ongoing training on RMC principles and the delivery of equitable care.

Reported respectful maternity care received during childbirth at health facilities: A cross sectional survey in Eastern province, Rwanda

BACKGROUND

Respectful maternity care (RMC) fosters positive childbirth experiences and ensures safe motherhood. While past Rwandan studies on childbirth predominantly focused on negative experiences, our research delved into positive experiences. This study aimed to assess the RMC level experienced by women during childbirth in health facilities of Eastern Province of Rwanda.

METHODOLOGY

We conducted a cross-sectional survey on 610 mothers at their discharge across five public hospitals. We used a 15-items RMC questionnaire developed by White Ribbon Alliance, version of 2019. To manage the right-skewed data, we employed a median cut-off, categorizing experiences into binary outcome (low and high RMC score). We performed stepwise backward elimination logistic regression model to identify predictors of high RMC.

FINDINGS

The majority (70.2%) reported experiencing RMC. The most acclaimed RMC items (over 90%) included allowance of food and fluid intake (98.5%), non-discrimination (96.2%), receipt of necessary services (96.1%), and privacy (91.3%). The chi-square analysis showed an association between reported high RMC and marital status (p-value = 0.006), occupation (p-value = 0.001), and mode of delivery (p-value = 0.001). Caesarean section delivery was associated with high RMC in multivariate logistic regression with a p-value of 0.001, the adjusted odds ratio was 2.11 with a CI [1.40-3.17].

CONCLUSION

The reported RMC items and care appreciated at high level should be sustained. Regardless of mode of delivery, all mothers should experience consistent, utmost respect throughout the childbirth and should receive RMC at maximum level.

Insights of healthcare professionals regarding waterbirths and water immersion during labour: A mixed studies review

AIM

To consolidate healthcare professionals' insights about waterbirths and water immersion during labour.

DESIGN

Mixed studies review.

DATA SOURCES

Seven electronic databases were searched from their inception dates till June 2023: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest Dissertations and Theses Global.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and Pluye and Hong's mixed studies review framework guided this review. The quality of included studies was evaluated using the Mixed Methods Appraisal Tool. Findings were synthesized using the convergent qualitative synthesis method, and results were thematically analysed using Braun and Clarke's framework.

RESULTS

Three main themes were identified from the 22 included studies: (1) believing in waterbirths, (2) opposing forces and (3) plotting the course ahead.

CONCLUSION

Healthcare professionals reported different views about waterbirths and water immersion practices; midwives were most likely to support these practices, followed by nurses and lastly, few physicians supported them. Reasons for opposing waterbirths include insufficient training and support from colleagues as well as concerns about work efficiency, waterbirth safety and litigation issues.

IMPACT

The available evidence suggests the need to provide waterbirth training for healthcare professionals, equip healthcare facilities with necessary waterbirth-related infrastructure and develop appropriate waterbirth policies/guidelines. Healthcare professionals could also consider providing antenatal waterbirth education to women and obtain women's feedback to improve current policies/guidelines. Future research should explore the views of different types of healthcare professionals from more diverse cultures.

REPORTING METHOD

The PRISMA guidelines.

NO PATIENT OR PUBLIC CONTRIBUTION

Systematic review.

Women's experiences of disrespect and abuse in Swiss facilities during the COVID-19 pandemic: a qualitative analysis of an open-ended question in the IMAgiNE EURO study

BACKGROUND

The COVID-19 pandemic has challenged the provision of maternal care. The IMAgiNE EURO study investigates the Quality of Maternal and Newborn Care during the pandemic in over 20 countries, including Switzerland.

AIM

This study aims to understand women's experiences of disrespect and abuse in Swiss health facilities during the COVID-19 pandemic.

METHODS

Data were collected via an anonymous online survey on REDCap®. Women who gave birth between March 2020 and March 2022 and answered an open-ended question in the IMAgiNE EURO questionnaire were included in the study. A qualitative thematic analysis of the women's comments was conducted using the International Confederation of Midwives' RESPECT toolkit as a framework for analysis.

FINDINGS

The data source for this study consisted of 199 comments provided by women in response to the open-ended question in the IMAgiNE EURO questionnaire. Analysis of these comments revealed clear patterns of disrespect and abuse in health facilities during the COVID-19 pandemic. These patterns include non-consensual care, with disregard for women's choices and birth preferences; undignified care, characterised by disrespectful attitudes and a lack of empathy from healthcare professionals; and feelings of abandonment and neglect, including denial of companionship during childbirth and separation from newborns. Insufficient organisational and human resources in health facilities were identified as contributing factors to disrespectful care. Empathic relationships with healthcare professionals were reported to be the cornerstone of positive experiences.

DISCUSSION

Swiss healthcare facilities showed shortcomings related to disrespect and abuse in maternal care. The pandemic context may have brought new challenges that compromised certain aspects of respectful care. The COVID-19 crisis also acted as a magnifying glass, potentially revealing and exacerbating pre-existing gaps and structural weaknesses within the healthcare system, including understaffing.

CONCLUSIONS

These findings should guide advocacy efforts, urging policy makers and health facilities to allocate adequate resources to ensure respectful and high-quality maternal care during pandemics and beyond.

Exploring women's experiences of care during hospital childbirth in rural Tanzania: a qualitative study

BACKGROUND

Women's childbirth experiences provide a unique understanding of care received in health facilities from their voices as they describe their needs, what they consider good and what should be changed. Quality Improvement interventions in healthcare are often designed without inputs from women as end-users, leading to a lack of consideration for their needs and expectations. Recently, quality improvement interventions that incorporate women's childbirth experiences are thought to result in healthcare services that are more responsive and grounded in the end-user's needs.

AIM

This study aimed to explore women's childbirth experiences to inform a co-designed quality improvement intervention in Southern Tanzania.

METHODS

This exploratory qualitative study used semi-structured interviews with women after childbirth (n = 25) in two hospitals in Southern Tanzania. Reflexive thematic analysis was applied using the World Health Organization's Quality of Care framework on experiences of care domains.

RESULTS

Three themes emerged from the data: (1) Women's experiences of communication with providers varied (2) Respect and dignity during intrapartum care is not guaranteed; (3) Women had varying experience of support during labour. Verbal mistreatment and threatening language for adverse birthing outcomes were common. Women appreciated physical or emotional support through human interaction. Some women would have wished for more support, but most accepted the current practices as they were.

CONCLUSION

The experiences of care described by women during childbirth varied from one woman to the other. Expectations towards empathic care seemed low, and the little interaction women had during labour and birth was therefore often appreciated and mistreatment normalized. Potential co-designed interventions should include strategies to (i) empower women to voice their needs during childbirth and (ii) support healthcare providers to have competencies to be more responsive to women's needs.

'Like a torch that enlightens new parents along a narrow and winding path into parenthood' - Midwives' experiences by an interview study

BACKGROUND

The core of postnatal care is that midwives recognise the needs of women and new-born babies and provide the highest possible quality of care and medical safety to optimise the health and well-being of new families. The study aimed to describe midwives' experiences in providing postnatal care for families during the first week after the birth of their baby.

METHODS

An interview study included 18 midwives who interchangeably worked within the models of traditional hospital care, hotel-based care, home-based care, hospital-based check-ups, and specialist care at a breastfeeding clinic at one university hospital in Sweden. Data collected were analysed using thematic analysis according to Braun and Clarke.

FINDINGS

The main theme: 'Like a torch that enlightens new parents along a narrow and winding path into parenthood - a midwife's transitional support' was explored and comprised two themes: (1) Strengthening parents' self-confidence in their parental role by handling over parental responsibility; and (2) Challenging to facilitate parents' understanding of their parental role.

CONCLUSIONS

Midwives expressed that supporting parents in the parental transition was a delicate task and included balancing mothers', babies', and partners' needs. The midwives guided parents into parenthood during postnatal care in a strategic manner by strengthening parents in their parental role. Postnatal care delivered by midwives is crucial for new parents and their babies.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Implementing a Respectful Maternity Care Guideline During Childbirth Experiences

OBJECTIVE

To measure the impact of an evidence-based guideline on respectful maternity care on nurses' attitudes and beliefs about childbirth practices.

DESIGN

A quality improvement pilot project with a pretest/posttest design examining the attitudes and beliefs of intrapartum nurses about childbirth practices of respectful care.

SETTING

High-risk intrapartum unit at a tertiary care center in the southeastern United States.

PARTICIPANTS

A convenience sample of 130 registered nurses were invited to participate, and nine completed the pre- and posttests.

INTERVENTION/MEASUREMENTS

The intervention included a recorded webinar, access to printed and electronic copies of the guideline, discussions in daily huddles, and a virtual journal club. Data were collected using the 42-item Nurse Attitudes and Beliefs Questionnaire-Revised. Lower scores are reflective of attitudes and beliefs that support a medical model of care, whereas higher scores are reflective of a physiologic model of care. Descriptive statistics and the Wilcoxon signed rank test were used to analyze changes in attitudes and beliefs based on the aggregate scores of the nurse participants.

RESULTS

Although there was no change in nurse attitude and beliefs about childbirth practices after 3 months (p = .058), the aggregate scores on a scale of 42 to 168 increased by 5.6 points. Two subscales of the Nurse Attitudes and Beliefs Questionnaire-Revised-Medical Model of Conflict and Women's Autonomy-had the greatest increase in aggregate scores.

CONCLUSION

Understanding nurses' attitudes and beliefs can assist in identifying barriers to the provision of respectful care, particularly during labor and birth, when patients are most vulnerable. Measurement of nurse attitudes and beliefs regarding respectful maternity care may require a longer immersion in a respectful maternity care program to allow for changes over time.

Perceptions of healthcare professionals regarding labour induction and augmentation: A qualitative systematic review

BACKGROUND

Labour induction and augmentation procedures are commonly used in maternity units with or without medical indications. Research shows that healthcare professionals play a significant role in women's childbirth decisions.

AIM

To consolidate healthcare professionals' perceptions about labour induction and augmentation.

METHODS

Seven electronic databases were searched from their inception dates till January 2023: PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest Dissertations, and Theses Global. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Sandelowski and Barroso's guidelines guided this review. Included studies' quality was appraised by the Critical Appraisal Skills Program tool. Data were thematically synthesised. Review findings were assessed using the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach.

FINDINGS

Three main themes were identified from the 17 included studies: 1) Making sense of the phenomenon, 2) Two sides of the coin, and 3) The enlightened path ahead.

DISCUSSION

Healthcare professionals' labour induction and augmentation decisions were affected by personal (knowledge and moral philosophies), and external factors (women, community members, colleagues, and healthcare institutions). Some clinicians were unfamiliar with the proper labour induction/augmentation procedures, while others were worried about their decisions and outcomes.

CONCLUSION

Suggestions for improvement include conducting labour induction/augmentation training for clinicians, having sufficient resources in facilities, and developing appropriate labour induction/augmentation clinical guidelines. Women and their partners, community members, and traditional healers could benefit from receiving labour induction/augmentation education. To improve health outcomes, healthcare professionals could deliver woman-centred care and collaborate.

Examination of Social Determinants of Health Characteristics Influencing Maternal Postpartum Symptom Experiences

Postpartum women experience multiple, co-occurring postpartum symptoms. It is unknown if social determinants of health (SDOH) influence postpartum symptom typologies. This secondary analysis used the Community and Child Health Network study data. Participants included for analysis varied depending on the availability of the SDOH data (N = 851 to 1784). Bivariate and multiple regression analyses were conducted to examine the association between SDOH and previously identified postpartum symptom typologies. Area under the receiver operating characteristics curve (AUROC) was calculated to examine if adding SDOH variables contributes to predicting postpartum symptom typologies. The adjusted odds (aOR) of being in high symptom severity or occurrence typologies were greater for participants who had less than high school education (aOR = 2.29), experienced healthcare discrimination (aOR = 2.21), used governmental aid (aOR = 2.11), or were food insecure (aOR = 2.04). AUROC improved after adding SDOH. Considering experiences of different social-economic hardships influence postpartum symptom typologies, future practice and research should address SDOH to improve postpartum symptom experiences.

Improving respectful maternity care through group antenatal care: findings from a cluster randomized controlled trial

Background

Disrespect and patient mistreatment are identified as barriers to care-seeking and low uptake of facility-based deliveries. These mitigating factors have led to slow progress in the achievement of maternal and child health targets, especially in Ghana. Group antenatal care, as an alternative to individual antenatal was implemented to explore the impact on outcomes, including mothers' perception of respectful care.

Methods

A cluster randomized controlled trial was conducted in 14 health facilities across four districts in the Easter Region of Ghana. These facilities were randomized to intervention or control using a matched pair. Data was collected at several timepoints: enrollment (Time 0), 34 weeks gestation to 3 weeks post-delivery (Time 1), 6 to 12 weeks post-delivery (Time 2), 5 to 8 months post-delivery (Time 3), and 11 to 14 months post-delivery (Time 4). Questions related to respectful care were asked at Time 2, while a focus group discussion (FGDs) was conducted as part of a process evaluation to examine participants' experiences about respectful maternity care.

Results

The findings from the intervention group indicate that participants perceived higher levels of respect in comparison to the control group. Privacy and con dentiality were maintained. They believed they had been provided with adequate information, education, and counseling, empowering them to make informed decisions. Participants perceived a shortened waiting time and reduced discrimination in care provision. Generally, there were higher levels of satisfaction with antenatal care.

Conclusion

The provision of respectful maternity care, which is essential to increasing healthcare utilization, has been demonstrated to correlate positively with group antenatal care.

Building confidence and trust in Ireland's National Maternity Services Workforce -What matters most and how?

National surveys on care experiences are increasingly adopted as regulatory mechanisms for improving care quality and increasing public trust in healthcare services. Based on data collected as part of Ireland's 2020 National Maternity Experience Survey, this study investigates care-related factors that contribute most to confidence and trust in the professional workforce (or carers) within Irish maternity services. The survey covered the full spectrum of maternity care and received 3,206 responses which were analysed using structural equation modelling. Results show that trust in carers may be enhanced through greater attention to the quality of interpersonal aspects of maternity care in a few core areas. We found that factors related to dignity and respect (β=0.270), involvement in decision-making (β=0.186), pain management (β=0.172), and communication (β=0.151) are core determinants of confidence and trust in the professional workforce of maternity services. Perceived quality of care in these four aspects increased on average, with the women's age. Women under 29 rated their experiences in these areas as significantly lower than the average. Women with a disability also rated their experiences significantly lower than average in three core areas. Our results suggest that trustworthy, equitable, and high-quality maternity care requires ongoing development of interpersonal skills within the maternity services professional workforce particularly in caring for younger women (under 29 years) and those with a disability.

Obstetric violence in the United States and other high-income countries: an integrative review

Obstetric violence has been documented throughout the world, yet this human rights issue has mostly been investigated in middle- and low-income countries where the intensity and brutality of abuse and mistreatment is more easily recognised as problematic. This integrative review aimed to analyse sources about obstetric violence in high-income countries with the objective of identifying gaps in the research, challenges to the study of obstetric violence, and solutions to framing research that meets those challenges. A systematic search was conducted using the PubMed and CINAHL databases from February to June 2022. Empirical and non-empirical sources, published in English, with no date restrictions, were retrieved. Citation searching was also done. Forty-six sources were included. Identified gaps in the research were: (a) scarce attention to obstetric violence in most high-income countries; (b) most US sources are non-scientific and from outside the healthcare disciplines; (c) inconsistencies in terminology; (d) most studies were conducted with samples of women who had given birth, with scant research about healthcare providers and obstetric violence, and (e) the association between obstetric violence and traumatic birth was under-recognised. Identified challenges to the study of obstetric violence were: (1) factors that enable and perpetuate obstetric violence are multilevel and nonlinear; (2) the phenomenon is contextually complex; and (3) blind spots from routinised harmful practices and normalised mistreatment can prevent healthcare providers and birthing people from recognising obstetric violence. A systems approach and complexity theory are guiding frameworks recommended as solutions to the challenges of studying and correcting obstetric violence.

Intrapartum care measures and indicators for monitoring the implementation of WHO recommendations for a positive childbirth experience: a scoping review

OBJECTIVE

We aimed to identify all available studies describing measures or indicators used to monitor 41 intrapartum care practices described in the 2018 WHO intrapartum care recommendations, with a view to informing development of standardised measurement of implementing these recommendations.

DESIGN

Systematic scoping review.

METHODS

We conducted a scoping review to identify studies reporting measures of intrapartum care published between 1 January 2000 and 28 June 2021. Primary and secondary outcome measures included study characteristics (publication year, journal, country and World Bank classification) and intrapartum care measure characteristics (definition, numerator, denominator, measurement level and measurement approach). We searched MEDLINE, EMBASE, CINAHL, Cochrane Library, the Maternity and Infant Care Database, Global Index Medicus and grey literature using structured search terms related to included recommendations, focusing on respectful and supportive care, and clinical practices performed throughout labour and birth. The measures identified were classified by the WHO recommendation and their characteristics reported.

RESULTS

We identified 150 studies which described 1331 intrapartum care measures. These measures corresponded to 35 of the 41 included WHO recommendations, and represented all domains of the WHO recommendations (care throughout labour and birth, first stage of labour, second stage of labour, third stage of labour). A total of 40.1% (534 of 1331 measures) of measures were related to respectful maternity care. Most studies used a questionnaire or survey measurement approach (522 of 1331 measures, 39.2%).

CONCLUSION

This scoping review presents a database of existing intrapartum care measures used to monitor the quality of intrapartum care globally. There is no clear consensus on a core set of measures for evaluating the practice of the WHO's intrapartum care recommendations. This review provides a foundation to support the development of a core set of internationally standardised intrapartum care measures for the WHO intrapartum care recommendations, highlighting key areas requiring consensus and validation, and measure development.

The birthing experiences of mothers with clinical healthcare professionals and community birth attendants in rural northern Ghana

BACKGROUND

The use of non-professional birth attendants, such as untrained family members and traditional birth attendants, contributes to birth-related complications such as neonatal and maternal mortality. Strategies such as professionally conducted home births and placement of community health professionals close to homes to ensure easy access to skilled birth attendants aim to reduce complications. However, women in labour continue to access the services of unskilled birth attendants in developing settings.

AIM

To explore the experiences of women in labour who received care from professional birth attendants and community birth attendants to understand the reasons for continued use of non-professional community birth attendants.

METHODS

A qualitative approach was used to explore the birthing experiences of nine mothers, aged 20-45 years. In-depth face-to-face interviews were conducted to generate data with the help of an interview guide. A content analysis approach was used to organise and interpret the data.

FINDINGS

The participants reported hostile interactions with professional birth attendants, imposition of birthing positions by professional birth attendants, high cost of birthing services by professional birth attendants, and safety risks with non-professional community birth attendants.

CONCLUSION

There is a need for explicit health financing systems that ensure mothers are aware and adequately prepared for labour-related costs. Mothers wish to receive care from professional birth attendants, but feel compelled by negative experiences to choose family members and non-professional birth attendants instead. The adherence of health professionals to the fundamental principles of 'Respectful Maternity Care' could reduce their negative attitudes towards women in labour.

Respectful Maternal Care Experience in Low- and Middle-Income Countries: A Systematic Review

Background and Objectives: Respectful maternity care promotes practices that acknowledge women's preferences and women and newborns' needs. It is an individual-centered strategy founded on ethical and human rights principles. The objective of this systematic review is to identify the impact of income on maternal care and respectful maternity care in low- and middle-income countries. Materials and Methods: Data were searched from Google Scholar, PubMed, Web of Science, NCBI, CINAHL, National Library of Medicine, ResearchGate, MEDLINE, EMBASE database, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Maternity and Infant Care database. This review followed PRISMA guidelines. The initial search for publications comparing low- and middle-income countries with respectful maternity care yielded 6000 papers, from which 700 were selected. The review articles were further analyzed to ensure they were pertinent to the comparative impact of income on maternal care. A total of 24 articles were included, with preference given to those published from 2010 to 2023 during the last fourteen years. Results: Considering this study's findings, respectful maternity care is a crucial component of high-quality care and human rights. It can be estimated that there is a direct association between income and maternity care in LMICs, and maternity care is substandard compared to high-income countries. Moreover, it is determined that the evidence for medical tools that can enhance respectful maternity care is sparse. Conclusions: This review highlights the significance of improving maternal care experiences, emphasizing the importance of promoting respectful practices and addressing disparities in low- and middle-income countries.

Effects of information-knowledge-attitude-practice health education combined with cluster-based care in patients with gestational hypertension

To analyze the impact of information-knowledge-attitude-practice (IKAP) health education incorporated with cluster-based care on blood pressure control, pregnancy outcome and life quality in those who have gestational hypertension, and to provide methodological backing for the care of patients. A total of 80 patients with pregnancy-induced hypertension were selected as the research objects and randomly divided into control and experimental groups, with 40 cases in each group. The control group received routine cluster care, which included providing individual and group health information through the distribution of health education manuals to hypertensive patients during pregnancy and their families. The experimental group received additional IKAP health education, including data collection, health knowledge imparted, concept change and behavior generation process. Blood pressure control status was measured and recorded. Adverse pregnancy outcomes include placenta previa, cesarean section, hyperamniotic fluid, fetal distress, and postpartum hemorrhage. Postpartum quality of life conditions, including physical activity, emotional awareness, physical discomfort, mental health, sleep quality, postpartum anxiety or depression, and general health were evaluated. Age, prepregnancy BMI, and educational level did not significantly vary between the 2 groups(P > .05). In comparison to the control group, the experimental group demonstrated healthier behavior. Blood pressure and weight control during pregnancy were better than control group. The frequency of adverse pregnancy was inferior to control group. The number of adverse neonatal conditions was inferior to control group. The postpartum quality of life score was higher in the experimental group compared to the control group. The combination of IKAP health education and cluster based care has a better effect on blood pressure control compared to the sole use of cluster based care. This approach can reduce the likelihood of experiencing adverse pregnancy outcomes and help improve the quality of life for patients after delivery.

Efficacy of midwife-led role orientation of birth companions on maternal satisfaction and birth outcomes: a randomized control trial in Uganda

BACKGROUND

The World Health Organization recommends birth companionship for all women in labor. There is insufficient evidence on birth companionship in low-income settings and it is not clear if role orientation impacts effectiveness. The aim of this study was to assess the efficacy of midwife-led role orientation of birth companions of on maternal satisfaction and birth outcomes in a sub-region in Uganda.

METHODS

A stepped wedge cluster randomized trial conducted (control n = 240), intervention n = 235) from 4 clusters. Women who had a birth companion, in spontaneously established labor and, expecting a vaginal delivery were eligible. The intervention was "midwife-provided orientation of birth companions". The admitting midwife provided an orientation session for the birth companion on supportive labor techniques. The primary outcome was the chance of having a spontaneous vaginal delivery. Assessors were not blinded. Independent t-test and Chi-Square tests were used to assess the differences by study period.

RESULTS

Mean maternal satisfaction rate was significantly higher in the intervention period compared to the control period (P > 0.001). High maternal satisfaction levels were noted among the women who were; at the regional referral hospital, younger, first-time mothers, and unmarried (P < 0.001). Satisfaction with pain management was rated lowest across study periods. Satisfaction with humaneness was rated highest with a higher score in the intervention period (93%) than the control (79.5%). There were no statistically significant differences in the mode of delivery, need to augment labor, length of labor and Apgar scores.

CONCLUSION

Midwife-led role orientation of birth companions increased maternal satisfaction. Nevertheless, no significant effect was noted in the mode of delivery, length of labor, Apgar score, and need to augment labor. Findings could inform the integration of birth companions in the admission process of the woman in labor in similar settings.

TRIAL REGISTRATION NUMBER

NCT04771325.

Vital Signs: Maternity Care Experiences - United States, April 2023

Introduction

Maternal deaths increased in the United States during 2018-2021, with documented racial disparities. Respectful maternity care is a component of quality care that includes preventing harm and mistreatment, engaging in effective communication, and providing care equitably. Improving respectful maternity care can be part of multilevel strategies to reduce pregnancy-related deaths.

Methods

CDC analyzed data from the PN View Moms survey administered during April 24-30, 2023, to examine the following components of respectful care: 1) experiences of mistreatment (e.g., violations of physical privacy, ignoring requests for help, or verbal abuse), 2) discrimination (e.g., because of race, ethnicity or skin color; age; or weight), and 3) reasons for holding back from communicating questions or concerns during maternity (pregnancy or delivery) care.

Results

Among U.S. mothers with children aged <18 years, 20% reported mistreatment while receiving maternity care for their youngest child. Approximately 30% of Black, Hispanic, and multiracial respondents and approximately 30% of respondents with public insurance or no insurance reported mistreatment. Discrimination during the delivery of maternity care was reported by 29% of respondents. Approximately 40% of Black, Hispanic, and multiracial respondents reported discrimination, and approximately 45% percent of all respondents reported holding back from asking questions or discussing concerns with their provider.

Conclusions and implications for public health practice

Approximately one in five women reported mistreatment during maternity care. Implementing quality improvement initiatives and provider training to encourage a culture of respectful maternity care, encouraging patients to ask questions and share concerns, and working with communities are strategies to improve respectful maternity care.

Midwives' and women's experiences with respectful maternity care around the globe: A meta-synthesis

BACKGROUND

All women have the right to the highest attainable standards of health, including the right to respectful maternity care (RMC). A qualitative body of knowledge describing midwives' and women's experiences of the value and importance of RMC exists. However, no qualitative synthesis exists about midwives' and women's views of respectful care.

AIM

This review aims to present a qualitative synthesis of global perceptions and experiences of midwives and women regarding RMC.

METHODS

A systematic search was conducted in October 2021 and updated in March 2023 on Science Direct, EBSCO host, PubMed, Nexus and ProQuest databases. The synthesis included qualitative studies published between 2010 and 2023. Qualified midwives and pregnant and postnatal women were the samples of the review. The studies' screening and selection for inclusion in the review are presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart, and the quality of the included studies was appraised using the Critical Appraisal Screening Programme (CASP) tool. Thematic analysis was conducted.

FINDINGS

Fifteen studies met the review inclusion criteria involving 266 women and 147 midwives. Five themes were identified from the data: commitment to women's rights; excellence in midwifery knowledge and skills; a facilitative built environment; optimising the interpersonal dimension; and the development of women's resourcefulness and resilience.

CONCLUSION

Maternity care is collaborative, and midwives and women are partners in the process. Midwives play a significant role in promoting women's rights, fostering interpersonal working and client relationships, and addressing women's rights and needs.

Mistreatment of women during childbirth and its influencing factors in public maternity hospitals in Tehran, Iran: a multi-stakeholder qualitative study

BACKGROUND

Mistreatment during labour and childbirth is a common experience for many women around the world. This study aimed to explore the manifestations of mistreatment and its influencing factors in public maternity hospitals in Tehran.

METHODS

A formative qualitative study was conducted using a phenomenological approach in five public hospitals between October 2021 and May 2022. Sixty in-depth face-to-face interviews were conducted with a purposive sample of women, maternity healthcare providers, and managers. Data were analyzed with content analysis using MAXQDA 18.

RESULTS

Mistreatment of women during labour and childbirth was manifested in four form: (1) physical abuse (fundal pressure); (2) verbal abuse (judgmental comments, harsh and rude language, and threats of poor outcomes); (3) failure to meet professional standards of care (painful vaginal exams, neglect and abandonment, and refusal to provide pain relief); and (4) poor rapport between women and providers (lack of supportive care and denial of mobility). Four themes were also identified as influencing factors: (1) individual-level factors (e.g., providers' perception about women's limited knowledge on childbirth process), (2) healthcare provider-level factors (e.g., provider stress and stressful working conditions); (3) hospital-level factors (e.g., staff shortages); and (4) national health system-level factors (e.g., lack of access to pain management during labour and childbirth).

CONCLUSIONS

Our study showed that women experienced various forms of mistreatment during labour and childbirth. There were also multiple level drivers for mistreatment at individual, healthcare provider, hospital and health system levels. Addressing these factors requires urgent multifaceted interventions.

Birth includes us: Development of a community-led survey to capture experiences of pregnancy care among LGBTQ2S+ families

BACKGROUND

Limited research captures the intersectional and nuanced experiences of lesbian, gay, bisexual, transgender, queer, two-spirit, and other sexual and gender-minoritized (LGBTQ2S+) people when accessing perinatal care services, including care for pregnancy, birth, abortion, and/or pregnancy loss.

METHODS

We describe the participatory research methods used to develop the Birth Includes Us survey, an online survey study to capture experiences of respectful perinatal care for LGBTQ2S+ individuals. From 2019 to 2021, our research team in collaboration with a multi-stakeholder Community Steering Council identified, adapted, and/or designed survey items which were reviewed and then content validated by community members with lived experience.

RESULTS

The final survey instrument spans the perinatal care experience, from preconception to early parenthood, and includes items to capture experiences of care across different pregnancy roles (eg, pregnant person, partner/co-parent, intended parent using surrogacy) and pregnancy outcomes (eg, live birth, stillbirth, miscarriage, and abortion). Three validated measures of respectful perinatal care are included, as well as measures to assess experiences of racism, discrimination, and bias across intersections of identity.

DISCUSSION AND CONCLUSIONS

By centering diverse perspectives in the review process, the Birth Includes Us instrument is the first survey to assess the range of experiences within LGBTQ2S+ communities. This instrument is ready for implementation in studies that seek to examine geographic and identity-based perinatal health outcomes and care experiences among LGBTQ2S+ people.

The Parturient Women's Privacy Preservation in the Delivery Rooms: A Qualitative Study

Introduction: Parturient women's privacy preservation and respectful maternity care (RMC) in delivery room is an important principle in the high quality of midwifery care to achieve maternal satisfaction and positive childbirth experience. Hence, it is essential to make natural vaginal delivery (NVD) a positive experience and increase the mothers' satisfaction. This study aimed to investigate the privacy preservation of parturient women's in the delivery room. Methods: Using conventional content analysis, this qualitative study was conducted from June 2018 to December 2020 at two hospitals and three health centers in Shahroud, Iran. Purposeful sampling was employed and it was continued till data saturation through in-depth interviews with 37 participants. Results: The results of interviews with 21 women with NVD experience and 16 maternity health service providers resulted in the extraction of four themes including physical, spiritual-mental, informational, and social privacy. Conclusion: Various mechanisms were found to promote the privacy and satisfaction of parturient women in the delivery room. They included the necessity continuous education, monitoring about mother's privacy preservation and intervention to improve effective communication skills among staff in delivery rooms.

Quality intrapartum care expectations and experiences of women in sub-Saharan African Low and Low Middle-Income Countries: a qualitative meta-synthesis

BACKGROUND

Woman-centred maternity care is respectful and responsive to women's needs, values, and preferences. Women's views and expectations regarding the quality of health services during pregnancy and childbirth vary across settings. Despite the need for context-relevant evidence, to our knowledge, no reviews focus on what women in sub-Saharan African Low and Low Middle-Income Countries (LLMICs) regard as quality intrapartum care that can inform quality guidelines in countries.

METHODS

We undertook a qualitative meta-synthesis using a framework synthesis to identify the experiences and expectations of women in sub-Saharan African LLMICs with quality intrapartum care. Following a priori protocol, we searched eight databases for primary articles using keywords. We used Covidence to collate citations, remove duplicates, and screen articles using a priori set inclusion and exclusion criteria. Two authors independently screened first the title and abstracts, and the full texts of the papers. Using a data extraction excel sheet, we extracted first-order and second-order constructs relevant to review objectives. The WHO framework for a positive childbirth experience underpinned data analysis.

RESULTS

Of the 7197 identified citations, 30 articles were included in this review. Women's needs during the intrapartum period resonate with what women want globally, however, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. Women received sub-quality intrapartum care and global standards for woman-centred care were often compromised. They were mistreated verbally and physically. Women experienced poor communication with their care providers and non-consensual care and were rarely involved in decisions concerning their care. Women were denied the companion of choice due to cultural and structural factors.

CONCLUSION

To improve care seeking and satisfaction with health services, woman-centred care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Research is needed to set minimum indicators for woman-centred outcomes for low-resource settings along with actionable strategies to enhance the quality of maternity care based on women's needs and preferences.

Intrapartum violence during facility-based childbirth and its determinants: A cross-sectional study among postnatal women in Tanzania

BACKGROUND

Violence during childbirth indirectly contributes to maternal and neonatal morbidity and mortality. It also causes intrapartum health consequences such as prolonged labor, postpartum hemorrhage, and postpartum psychological problems, including postpartum depression, post-traumatic stress disorder, and other negative feelings that lead to a decreased desire for facility delivery and increase the events of home deliveries which reduce the quality of life. In Tanzania, several efforts have been made to promote respectful maternity care. However, violence during childbirth continues to create a critical barrier for facility-based delivery and is in need of considerable attention throughout the health system.

OBJECTIVES

This study aimed to assess types of intrapartum violence and its determinants among postnatal women in the Dodoma Region, Tanzania.

DESIGN

A cross-sectional study using a questionnaire to interview postnatal women at the exit point after being discharged from the health facility to assess intrapartum violence and its determinants.

METHODS

This study was conducted in Dodoma Region involving 307 postnatal women from April to June 2022. A simple random method was used to select respondents. The Chi-square and Fisher's exact tests were used to assess the association between the categorical variables. The predictors of intrapartum violence were determined using binary logistic regression analysis. Statistical analysis was performed using Statistical Package for Social Science version 25.0. P < 0.05 was considered to be significant.

RESULTS

Overall, 307 postnatal women participated in the study. Among them, 158 (51.5%) postnatal women experienced at least one form of intrapartum violence. The most common forms of intrapartum violence included breach of confidentiality 205 (66.8%), undignified care/verbal abuse 178 (58%), physical abuse 139 (45.3%), and denial or neglected care by midwives 113 (36.8%). Husband employment, urban residence, and being referred from primary hospitals were significant determinants associated with intrapartum violence (adjusted odds ratio = 0.233, 95% confidence interval = 0.057-0.952, p = 0.043, adjusted odds ratio = 2.67, 95% confidence interval = 1.13-10.93, p = 0.026 and adjusted odds ratio = 3.673, 95% confidence interval = 1.131-11.934, p = 0.030, respectively).

CONCLUSION

Violence during childbirth was highly prevalent in this study. Understanding the prevalence and types of intrapartum violence is important in order to promote changes in all levels of the health system. This study reveals the need for key interventions to effect change at many levels; including an interventional study to educate women and birth partners on client rights, and strengthening the health system to meet the needs of women during labor and childbirth. Policies and systems that support respectful maternity care are urgently needed in this setting, including universal training of health professionals in respectful maternity care.

Providing gender affirming and inclusive care to transgender men experiencing pregnancy

OBJECTIVES AND DESIGN

Information about providing professional and appropriate perinatal care to transgender men in the perinatal setting is scarce, and healthcare providers often have insufficient knowledge or skills to provide this care. In response, a quality improvement educational program for nursing staff was developed and implemented, with the goal of evaluating the impact of this intervention on nurses' knowledge, skills, and attitudes when caring for pregnant transgender men.

SETTING AND PARTICIPANTS

The training was offered to nursing staff of a 24-bed inpatient perinatal unit at a large, private academic medical center in a major East Coast city during the unit's quarterly staff meeting in March 2020.

INTERVENTION

The training covered the provision of affirming and inclusive perinatal care for transgender men. The content of the training was based on recommendations in the literature and reviewed by content experts.

MEASUREMENTS

Pre-test (N = 55) and post-test (N = 23) online self-administered surveys assessed nursing staff's knowledge of, comfort, and interest in providing gender affirming care for transgender men. Mann-Whitney U and Fischer's exact tests were used to determine significant changes in knowledge and attitudes over time.

FINDINGS

Findings suggest the training improved nursing staff's self-reported knowledge and skills in providing gender affirming care to pregnant transgender men over time, with participants demonstrating improved knowledge about communication around pronouns, gender identity, reproductive systems, and obstetric history. Awareness of resources for both professional development and to refer transgender patients also improved. However, persistent deficits in other knowledge, skills, and attitudes remained, suggesting that nurses would likely benefit from further support and training in transgender-specific health issues.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Findings support the utility of unit-based training in improving affirming and inclusive care in the perinatal setting. This highlights opportunities for supporting nurses' professional practice of caring for transgender patients experiencing pregnancy and may be adapted for use in other specialty units.

Quality of health care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Norway and trends over time

OBJECTIVE

To describe maternal perception of the quality of maternal and newborn care (QMNC) in facilities in Norway during the first year of COVID-19 pandemic.

METHODS

Women who gave birth in a Norwegian facility from March 1, 2020, to October 28, 2021, filled out a structured online questionnaire based on 40 WHO standards-based quality measures. Quantile regression analysis was performed to assess changes in QMNC index over time.

RESULTS

Among 3326 women included, 3085 experienced labor. Of those, 1799 (58.3%) reported that their partner could not be present as much as needed, 918 (29.8%) noted inadequate staff numbers, 183 (43.6%) lacked a consent request for instrumental vaginal birth (IVB), 1067 (34.6%) reported inadequate communication from staff, 78 (18.6%) reported fundal pressure during IVB, 670 (21.7%) reported that they were not treated with dignity, and 249 (8.1%) reported experiencing abuse. The QMNC index increased gradually over time (3.68 points per month, 95% CI, 2.83-4.53 for the median), with the domains of COVID-19 reorganizational changes and experience of care displaying the greatest increases, while provision of care was stable over time.

CONCLUSION

Although several measures showed high QMNC in Norway during the first year of the COVID-19 pandemic, and a gradual improvement over time, several findings suggest that gaps in QMNC exist. These gaps should be addressed and monitored.

The role of doulas in respectful care for communities of color and Medicaid recipients

BACKGROUND

Despite the tenets of rights-based, person-centered maternity care, racialized groups, low-income people, and people who receive Medicaid insurance in the United States experience mistreatment, discrimination, and disrespectful care more often than people with higher income or who identify as white. This study aimed to explore the relationship between the presence of a doula (a person who provides continuous support during childbirth) and respectful care during birth, especially for groups made vulnerable by systemic inequality.

METHODS

We used data from 1977 women interviewed in the Listening to Mothers in California survey (2018). Respondents who reported high levels of decision making, support, and communication during childbirth were classified as having "high" respectful care. To examine associations between respectful care and self-reported doula support, we conducted multivariable logistic regressions. Interactions by race/ethnicity and private or Medi-Cal (Medicaid) insurance status were assessed.

RESULTS

Overall, we found higher odds of respectful care among women supported by a doula than those without such support (odds ratios [OR]: 1.4, 95% CI: 1.0-1.8). By race/ethnicity, the association was largest for non-Hispanic Black women (2.7 [1.1-6.7]) and Asian/Pacific Islander women (2.3 [0.9-5.6]). Doula support predicts higher odds of respectful care among women with Medi-Cal (1.8 [1.3-2.5]), but not private insurance.

CONCLUSIONS

Doula support was associated with high respectful care, particularly for low-income and certain racial/ethnic groups in California. Policies supporting the expansion of doulas for low-income and marginalized groups are consistent with the right to respectful care and may address disparities in maternal experiences.

The design, delivery and evaluation of 'Human Perspectives VR': An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD

BACKGROUND

A traumatic childbirth experience affects ~30% of women each year, with negative impacts on maternal, infant, and family wellbeing. Women classified as vulnerable or marginalised are those more likely to experience a psychologically traumatising birth. A key contributory factor for a traumatic childbirth experience is women's relationships with maternity care providers.

AIMS

To develop, design and evaluate an immersive educational programme for maternity care providers to raise awareness of traumatic childbirth experiences amongst vulnerable groups, and ultimately to improve women's experiences of childbirth.

METHODS

A critical pedagogical approach that utilised virtual reality (VR) underpinned the design and development of the educational programme. This involved: a) collecting vulnerable/disadvantaged women's experiences of birth via interviews; b) analysing data collected to identify key hotspots for traumatic experiences within interpersonal patient-provider relationships to develop a script; c) filming the script with professional actors creating a first person perspective via VR technology; d) using existing literature to inform the theoretical and reflective aspects of the programme; e) conducting an evaluation of the education programme using pre-and post-evaluation questionnaires and a follow-up focus group.

FINDINGS

Human Perspective VR was very well received. Participants considered the content to have enhanced their reflective practice and increased their knowledge base regarding contributory factors associated with a traumatic childbirth experience. A need for further work to implement learning into practice was highlighted.

CONCLUSION

While further research is needed to evaluate the impact of the programme, Human Perspective VR programme offers an innovative approach to reflective education and to enhance participants' care practices.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Perceptions and predictors of respectful maternity care in Malawi: A quantitative cross-sectional analysis

OBJECTIVE

Access to high-quality, respectful care is a basic human right. A lack of respectful care during childbirth is associated with poor outcomes and can negatively influence care-seeking and maternal mental health. We aimed to describe how women perceive their experience of maternity care in Malawi.

METHODS

We implemented a cross-sectional survey of women (n = 660) who delivered in 25 birth facilities in four districts in Malawi in March 2020 using a validated 30-item, 90-point person-centered maternity care (PCMC) scale. We used descriptive statistics to examine women's experience of care and analyzed bivariable and multivariable mixed-effects models to evaluate predictors of PCMC. Statistical models accounted for clustering of women at the facility level and included maternal age, marital status, education, parity, mother or infant complications, timing of antenatal care (ANC), provider cadre and gender, facility type and sector, and district.

RESULTS

Mean PCMC score was 57.5 (range 21-84), with the lowest score (12.4 of 27 points) in communication and autonomy. Women reported: being prohibited from having a birth companion during labor (49.4%) or delivery (60.3%); providers did not introduce themselves (81.1%); providers did not ask consent before procedures/examinations (42.4%); women felt they could not ask questions (40.9%); and were not involved in care decisions (61.5%). Few women reported being frequently abused physically (2%) or verbally (3.5%); almost all had water/electricity available (>95%). In bivariate analyses, statistically significant positive associations were found between PCMC score and early ANC, male accompaniment to the facility, male provider, and a lack of complications; all associations remained at least potentially statistically significant in multivariable modeling.

CONCLUSIONS

Physical and verbal abuse and a lack of basic amenities were rare, while a lack of communication with patients and social support were common. Maternal characteristics (like timing of ANC and maternal or newborn complications) were predictors of RMC, while facility/system factors, like facility type and sector, were not. Continued efforts to improve respectful care will require strengthening provider communication skills and encouraging patient and companion involvement in care.

Culturally appropriate care to support maternal positions during the second stage of labour: Midwives' perspectives in South Africa

Background

‘Doing what the Romans do in Rome’ was an expression raised by one of the midwives following workplace culture and disregarding women’s birth choices. Midwifery practice in South Africa caters for a culturally diverse ethnic groups of childbearing women. Culturally appropriate care highlights the importance of including women in decision-making concerning their birth preferences including maternal positions during labour. Women’s right to choose their maternal position and cultural preferences during labour has been overlooked, leading to poor maternal healthcare provision and negative birth experiences.

Aim

In this article, the researchers aimed to describe and explore midwives’ perspectives on culturally appropriate care to support maternal positions during the second stage of labour.

Setting

Midwives working in the maternity ward in a public hospital in South Africa.

Methods

A qualitative descriptive design using individual interviews was used to collect data. The participants were selected using the purposive sampling method. The study population comprised 20 midwives who volunteered to participate in the study. Data were transcribed manually and analysed using thematic analysis.

Results

The four main themes are as follows: (1) Caring for women from various ethnic groups, (2) midwives disregard women’s beliefs and culture, (3) midwife personal cultural attributes and (4) midwifery unit workplace culture.

Conclusion

The authors concluded that culturally appropriate care towards the women’s choices of birth position during the second stage of labour should form an integral part of the midwifery care rendered.

Determining a Trusting Environment for Maternity Care: A Framework Based on Perspectives of Women, Communities, Service Providers, and Managers in Peri-Urban Kenya

Trust in health service providers and facilities is integral to health systems accountability. Understanding determinants of trust, a relational construct, in maternity settings necessitates exploring hierarchical perspectives of users, providers, and influencers in the care environment. We used a theoretically driven qualitative approach to explore trust determinants in a maternity setting across patient-provider, inter-provider, and community-policymaker interactions and relationships in peri-urban Kenya. Focus groups (n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews (n = 33) with WRB, health care providers and managers, and community health workers (CHWs) were conducted in 2013, soon after the national government's March 2013 introduction of a policy mandate for "Free Maternity Care." We used thematic coding, memo writing, and cross-perspective triangulation to develop a multi-faceted trust determinants framework. We found that determinants of trust in a maternity setting can be broadly classified into six types of factors, where each type of factor represents a cluster of determinants that may each positively or negatively influence trust: patient, provider, health facility, community, accountability, and structural. Patient factors are prior experiences, perceived risks and harms, childbirth outcomes, and maternal health literacy. Provider factors are empathy and respect, responsiveness, and perceived capability of providers. Health facility factors are "good services" as perceived by patients, physical environment, process navigability, provider collaboration and oversight, discrimination, and corruption. Community factors are facility reputation and history, information channels, and maternal health literacy. Accountability factors are alignment of actions with expectations, adaptations to policy changes, and voice and feedback. Structural factors are institutional hierarchies and policies in the form of professional codes. Trust determinants are complex, nuanced and reflect power dynamics across relationships. Findings offer insight into socio-political maternity norms and demand a more equitable care interface between users and providers.

Mistreatment during childbirth and postnatal period reported by women in Nepal —a multicentric prevalence study

Introduction

Trust of women and families toward health institutions has led to increased use of their services for childbirth. Whilst unpleasant experience of care during childbirth will halt this achievement and have adverse consequences. We examined the experience of women regarding the care received during childbirth in health institutions in Nepal.

Method

A prospective cohort study conducted in 11 hospitals in Nepal for a period of 18 months. Using a semi-structured questionnaire based on the typology of mistreatment during childbirth, information on childbirth experience was gathered from women (n = 62,926) at the time of discharge. Using those variables, principal component analysis was conducted to create a single mistreatment index. Bivariate and multivariate linear regression analyses were conducted to assess the association of the mistreatment index with sociodemographic, obstetric and newborn characteristics.

Result

A total of 62,926 women were consented and enrolled in the study. Of those women, 84.3% had no opportunity to discuss any concerns, 80.4% were not adequately informed before providing care, and 1.5% of them were refused for care due to inability to pay. According to multivariate regression analysis, women 35 years or older (β, − 0.3587; p-value, 0.000) or 30–34 years old (β,− 0.38013; p-value, 0.000) were less likely to be mistreated compared to women aged 18 years or younger. Women from a relatively disadvantaged (Dalit) ethnic group were more likely to be mistreated (β, 0.29596; p-value, 0.000) compared to a relatively advantaged (Chettri) ethnic group. Newborns who were born preterm (β, − 0.05988; p-value, 0.000) were less likely to be mistreated than those born at term.

Conclusion

The study reports high rate of some categories of mistreatment of women during childbirth. Women from disadvantaged ethnic group, young women, and term newborns are at higher risk of mistreatment. Strengthening health system and improving health workers’ readiness and response will be key in experience respectful care during childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04639-6.

Care ethics framework for midwifery practice: A scoping review

Background: As a normative theory, care ethics has become widely theorized and accepted. However, there remains a lack of clarity in relation to its use in practice, and a care ethics framework for practice. Maternity care is fraught with ethical issues and care ethics may provide an avenue to enhance ethical sensitivity.Aim: The purpose of this scoping review is to determine how care ethics is used amongst health professions, and to collate the information in data charts to create a care ethics framework and definition for midwifery practice.Method: The scoping review was conducted according to the Preferred Reporting Items for Scoping reviews (PRISMA-ScR) and Joanna Briggs Institute (JBI) recommendations. The search was applied to the databases CINAHL, MEDLINE, PschInfo and Pubmed which were searched in September 2019 and again in July 2021. The inclusion criteria were guided by the mnemonic for search terms: Participants, Concept, and Context (PCC) and included variations of health care professionals, care ethics and utilization. The search was limited to qualitative studies published in English between 2010 and 2021. A data extraction tool was used to extract and synthesize data into categories. The articles were screened for eligibility by title, abstract and full text review, by two independent reviewers.Ethical Considerations: The scoping review was guided by ethical conduct respecting authorship and referencing sources.Results: Twelve of the initially identified 129 studies were included in the scoping review. Data synthesis yielded four categories of care ethics use by health professionals: relationship, context, attention to power and caring practices. In combination, the evidence forms a framework for care ethics use in midwifery practice.Conclusion: Care ethics use by health professionals enhances ethical sensitivity. A framework and definition for care ethics for midwifery practice is proposed. This review will be of interest to midwives and other health practitioners seeking to enhance ethical sensitivity.

The effect of backup midwife on maternal experience after vaginal childbirth - a qualitative study

One of the goals of reproductive health enhancement is to ensure the desired experience of safe childbirth by reducing possible complications, fears, and worries about delivery by ongoing midwife backup care. This study explains women's experiences with a backup midwife during labor and childbirth. This was a qualitative study involving 19 women who had natural childbirth in Hamadan, 2020. Purposeful sampling and data collection were performed using semi-structured in-depth interviews. Data were analyzed by conventional content analysis using MAXQDA software version 10. Data analysis showed three themes and six main categories. The themes included security, high-quality care, and respectful care, consisting of two main categories of perceived empowerment and support, physiological approach and reassuring care, and respect for the mother's privacy and optimal accountability. The presence of a backup midwife during labor caused a sense of security, control, and perceived empowerment, thus a positive childbirth experience. Therefore, it is necessary to train and employ midwifery in the healthcare system. It is recommended to train and employ midwifery graduates for this purpose and include it as one of the basic principles in the current planning to promote natural childbirth.

'We felt like part of a production system': A qualitative study on women's experiences of mistreatment during childbirth in Switzerland

INTRODUCTION

Mistreatment during childbirth is an issue of global magnitude that not only violates fundamental human rights but also seriously impacts women's well-being. The purpose of this study was to gain a better understanding of the phenomenon by exploring the individual experiences of women who reported mistreatment during childbirth in Switzerland.

MATERIALS AND METHODS

This project used a mixed methods approach to investigate women's experiences of mistreatment during childbirth in general and informal coercion specifically: The present qualitative study expands on the findings from a nationwide online survey on childbirth experience. It combines inductive with theoretical thematic analysis to study the 7,753 comments women wrote in the survey and the subsequent interviews with 11 women who reported being mistreated during childbirth.

RESULTS

The women described a wide range of experiences of mistreatment during childbirth in both the survey comments and the interviews. Out of all survey participants who wrote at least one comment (n = 3,547), 28% described one or more experiences of mistreatment. Six of the seven types of mistreatment listed in Bohren and colleagues' typology of mistreatment during childbirth were found, the most frequent of which were ineffective communication and lack of informed consent. Five additional themes were identified in the interviews: Informal coercion, risk factors for mistreatment, consequences of mistreatment, examples of good care, and what's needed to improve maternity care.

CONCLUSION

The findings from this study show that experiences of mistreatment are a reality in Swiss maternity care and give insight into women's individual experiences as well as how these affect them during and after childbirth. This study emphasises the need to respect women's autonomy in order to prevent mistreatment and empower women to actively participate in decisions. Both individual and systemic efforts are required to prevent mistreatment and guarantee respectful, dignified, and high-quality maternity care for all.

From coercion to respectful care: women's interactions with health care providers when planning a VBAC

BACKGROUND

In many countries caesarean section rates are increasing and this impacts on choices made around mode of birth in subsequent pregnancies. Having a vaginal birth after caesarean (VBAC) can be a safe and empowering experience for women, yet most women have repeat caesareans. High caesarean section rates increase maternal and neonatal morbidity, health costs and burden on hospitals. Women can experience varied support from health care providers when planning a VBAC. The aim of this paper is to explore the nature and impact of the interactions between women planning a VBAC and health care providers from the women's perspective.

METHODS

A national Australian VBAC survey was undertaken in 2019. In total 559 women participated and provided 721 open-ended responses to six questions. Content analysis was used to categorise respondents' answers to the open-ended questions.

RESULTS

Two main categories were found capturing the positive and negative interactions women had with health care providers. The first main category, 'Someone in my corner', included the sub-categories 'belief in women birthing', 'supported my decisions' and 'respectful maternity care'. The negative main category 'Fighting for my birthing rights' included the sub-categories 'the odds were against me', 'lack of belief in women giving birth' and 'coercion'. Negative interactions included the use of coercive comments such as threats and demeaning language. Positive interactions included showing support for VBAC and demonstrating respectful maternity care.

CONCLUSIONS

In this study women who planned a VBAC experienced a variety of positive and negative interactions. Individualised care and continuity of care are strategies that support the provision of positive respectful maternity care.

Contextual factors influencing a training intervention aimed at improved maternal and newborn healthcare in a health zone of the Democratic Republic of Congo

Background

Maternal and neonatal mortality and morbidity in the Democratic Republic of Congo (DRC) are among the highest worldwide. As part of a quality improvement programme in a health zone in the DRC aimed at contributing to reduced maternal and neonatal mortality and morbidity, a three-pillar training intervention around childbirth was developed and implemented in collaboration between Swedish and Congolese researchers and healthcare professionals. The aim of this study is to explore contextual factors influencing this intervention.

Methods

A qualitative research design was used, with data collected through focus group discussions (n = 7) with healthcare professionals involved in the intervention before and at the end (n = 9). Transcribed discussions were inductively analysed using content analysis.

Results

Three generic categories describe the contextual factors influencing the intervention: i) Incentives motivated participants’ efforts to begin a training programme; ii) Involving the local health authorities was important; and (iii) Having physical space, electricity, and equipment in place was crucial.

Conclusions

This study and similar ones highlight that incentives of various types are crucial contextual factors that influence training interventions, and have to be considered already in the planning of such interventions. One such factor is expectations of monetary incentives. To meet this in a small research project like ours would require a reduction of the scale and thus limit the implementation of new evidence-based knowledge into practice aimed at reducing maternal mortality and morbidity.

Maternal-infant bonding for the opioid exposed dyad: A rodgers' evolutionary concept analysis

AIM

This concept analysis aimed to offer insight into how opioid exposure affects the quality and construction of the maternal-infant bond.

BACKGROUND

Maternal-infant bonding can be influenced by maternal opioid use disorder and the neonatal intensive care unit environment. Many interventions for mothers with opioid use disorder focus on enhancing parental skills, but often the emotional and relational features of the maternal-infant bond have been overlooked.

DATA SOURCE

Literature from Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PubMed, and PsycINFO published from January 2011 to June 2021 using "attachment theory," "mother-infant attachment," "maternal-infant bonding," "neonatal opioid withdrawal syndrome," and "neonatal abstinence syndrome" as key terms.

REVIEW METHODS

Rodgers' method of concept analysis was used to determine the antecedents, attributes, and consequences of maternal-infant bonding.

RESULTS

The key attributes of bonding for the opioid-exposed mother-infant dyad are engaged mothering, recognition of risk, affection, and respectful maternity care. The antecedents are closeness, selflessness, and purposeful touch. The consequences are sobriety, custody, love, and security.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review

BACKGROUND

Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.

METHODS

Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.

RESULTS

Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.

CONCLUSIONS

Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

What women emphasise as important aspects of care in childbirth - an online survey

OBJECTIVE

To explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth.

DESIGN

The study is based on data from the Babies Born Better online survey, version 2.

SETTING

The maternity care system in Norway.

STUDY POPULATION

Women who gave birth in Norway between 2013 and 2018.

METHOD

Descriptive statistics were used to describe sample characteristics and to compare data from the B3 survey with national data from the Medical Birth Registry of Norway. The open-ended questions were analysed with an inductive thematic analysis.

MAIN OUTCOME MEASURES

Themes developed from two open-ended questions.

RESULTS

The final sample included 8401 women. There were no obvious differences between the sample population and the national population with respect to maternal age, marital status, parity, mode of birth and place of birth, except for the proportion of planned home births. Four themes and one overarching theme were identified; Compassionate and Respectful Care, A Family Focus, Sense of Continuity and Consistency, and Sense of Security. Overarching theme: Coherence in Childbearing.

CONCLUSIONS

Norwegian women across all birth settings emphasise maternity care that authentically focuses on both socio-cultural and psychological aspects of care, and physical and clinical factors. If the positive aspects of care identified in this study are adopted at all levels of the maternity care system and from all care providers, there is a high chance that most women will have a safe outcome, and a strong sense of coherence related to a positive birth and motherhood experience.

TWEETABLE ABSTRACT

Having a baby is a pivotal life changing experience and not just a clinical event, according to a survey of 8400 women in Norway. Positive birth and motherhood experiences depend on maternity staff who are both skilled and kind.

A cross-sectional study to evaluate antenatal care service provision in 3 hospitals in Nepal

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Assessing respectful maternity care in a fragile, conflict-affected context: Observations from a 2016 national assessment in Afghanistan

Evidence on experiences and perceptions of care in pregnancy and childbirth in conflict-affected settings is limited. We interviewed 561 maternity care providers and observed 413 antenatal care consultations, 671 births, and 393 postnatal care consultations at public health facilities across Afghanistan. We found that healthcare providers work under stressed conditions with insufficient support, and most women receive mixed quality care. Understanding socio-cultural and contextual factors underpinning acceptance of mistreatment in childbirth, related to conflict, insecurity, gender and power dynamics, is critical for improving the quality of maternity care in Afghanistan and similar fragile and conflict affected settings.