Abstract

Background: Respectful maternity care is critical to the health of birthing people and infants worldwide. However, there is global evidence of disrespectful or abusive care in childbirth, which negatively impacts maternal experiences and health outcomes. Maternal health care providers hold key insights into the dynamics of quality of care in childbirth. The aim of this systematic review is to synthesize the perspectives of health care providers’ perceptions of respectful and disrespectful care in childbirth. Methods: We searched PubMed, CINAHL, HOLLIS (Harvard Medical Library), and Medline database for peer-reviewed quantitative and qualitative research studies examining health care providers’ perceptions of respectful and disrespectful maternity care published between January 2014 and July 2024. Quantitative studies were summarized, and qualitative studies were synthesized thematically. A mixed-method summary integrated findings from both quantitative and qualitative findings. Results: Sixty studies (15 quantitative, 39 qualitative, and 6 mixed methods) were included. Prevalence of witnessing disrespect and abuse in childbirth ranged widely, from 21.9% to 93.2%. Types of respectful and disrespectful care witnessed and performed by maternal health care providers varied greatly. Four themes were identified from qualitative studies: 1—facility and structural issues, 2—clinician responsibilities, 3—hierarchy and power, and 4—(mis)understanding and interpreting the mother’s experience. Both qualitative and quantitative studies identified three issues. Reduced staffing was a barrier to respectful maternity care. A lack of privacy was a key issue. Finally, providers expressed a need for training on respectful maternity care. Conclusions: This review found a wide variety of metrics quantifying respectful and disrespectful maternity care, and a diversity of knowledge and perceptions held by health care providers. The global scope of the review revealed that the manifestation of respectful and disrespectful care varied greatly by cultural and institutional context, and that organizational resources significantly impacted quality of care.

Keywords

Respectful Maternity Care, Disrespect and Abuse, Childbirth

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1. Introduction

Respectful, safe, and accessible obstetricalcare is a cornerstone for a functioning healthcare system and a stable and resourced society that values all its citizens. Maternal care includes all aspects of pregnancy-focused care, ranging from antepartum, intrapartum, and postpartum care. The intrapartum phase includes the dynamic and changing period of labor and delivery, where a birthing person and their infant are most vulnerable to medically critical and life-threatening events. A birthing person is a gender-neutral designation of someone who is pregnant or in the process of giving birth. The American College of Obstetricians and Gynecologists (ACOG) has identified the importance of establishing levels of maternal care that include basic care, specialty care, subspecialty care, and regional perinatal healthcare centers to reduce maternal mortality and severe maternal morbidity [1]. Maternal mortality is defined as deaths due to complications of pregnancy, delivery, or the first 42 days after delivery per 100,000 live births. Pregnancy-related deaths, a significant cause of death for women worldwide, have largely been due to lack of access to healthcare centers and unattended home deliveries. Hemorrhage, cardiovascular disease, and infection are the leading direct causes of maternal death in both high- and lower-income regions [2]-[4]. Enormous strides have been made in increasing access to skilled maternity care, especially during the World Health Organization’s (WHO) Millennium Development Goal era (2000-2015) [5]. However, global progress in tackling maternal mortality has since stalled. The reasons are multifactorial. Gender biases deprioritize women’s health care and stigma presents a barrier to comprehensive reproductive health worldwide [6]. Humanitarian crises strain health care systems. Inequities in race, income, and education put subpopulations at greater risk [6]. Currently, healthcare systems operate in the long shadow of the COVID-19 pandemic, with system deficiencies—some that predate the pandemic and some that were exacerbated by it—limiting the ability of maternal care facilities unable to provide quality care [7].

Lack of respectful maternity care has emerged as a critical byproduct of such healthcare systemic deficiencies. Birthing people who experience disrespect and abuse in childbirth are more likely to avoid or delay health care in the future, putting them at risk for poor outcomes [8]. Those who experience disrespect, abuse, or violence during childbirth face the possibility of psychological trauma [9] [10], postpartum depression [11], and avoidance of health care services, leading to poorer maternal outcomes overall [12] [13]. The consequent decrease in rates of facility-based birth poses an additional barrier to reducing the rates of global maternal morbidity and mortality [14].

Though there is widespread observational evidence of birthing people’s negative experiences, there is no standardized definition for disrespectful maternity care. A great deal of discourse exists regarding the conceptualization and terminology of the phenomenon. Obstetric violence, or violence against birthing people during childbirth, is conceptualized as an infringement of the human rights of birthing people and a dimension of gender-based violence [15] [16]. Several Latin American countries have developed a legal framework to criminalize such violence [16]-[18]. The most salient definition is found in the landmark 2007 Venezuelan law, “Organic Law on the Right of Women to a Life Free of Violence”, which defines obstetric violence as follows:

…The appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women [19].

However, the use of the term “obstetric violence” engenders controversy. The term may alienate health care professionals, who are vital stakeholders in the pursuit of respectful maternity care [20]-[22]. The currently preferred terminology, “disrespect and abuse in childbirth” and “mistreatment in facility-based birth”, attempts to soften language and recruit obstetrical providers in efforts to improve care [15] [23]. Bohren et al. (2015) developed a framework of seven categories of mistreatment: physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints [24]. Some dimensions of disrespect and abuse may be culture and context specific [25]. In a WHO-sponsored analysis of social determinants of health across the 53 Member States of the European Region, health inequities and mortality outcomes were tracked with socioeconomic status by country [26]. The resources of health systems correlated with national income, social development, and politics of each country [26]. In low- and middle-income countries, respectful maternity care has a direct association with the income of the country [27].

Recognizing that the absence of abusive care alone does not constitute quality care, the concept of “Respectful Maternity Care” (RMC) has recently gained traction. RMC aims to not only eliminate harm but also maintain and respect the birthing person’s dignity, privacy, and confidentiality. As such, it is an important dimension of healthcare quality and can be operationalized by healthcare systems as part of quality improvement and safety initiatives [28]. Such debate and diversity in conceptualization and terminologies regarding quality care in childbirth necessitate an inclusive review that encompasses respectful maternity care, disrespect and abuse in childbirth, and obstetric violence. As such, the term and concept of respectful maternity care is defined as medical care encompassing the rights, privacy, autonomy, and dignity of each birthing person during the delivery of maternity services [5].

Most studies in this realm focus exclusively on the experiences of birthing people [13] [24]. The perspectives of maternal healthcare providers have been comparatively unexplored, leaving a gap in the understanding of this topic. Providers can perpetrate violence and provide disrespectful care to vulnerable parturient people; they can also hold negative attitudes that translate into harmful patient interactions [29]. Additionally, providers can be subject to vulnerabilities themselves, such as punishing workloads in dysfunctional or under-resourced environments, which may lead to provider burnout and suboptimal care for patients [30] [31]. As both agents of and witnesses to these behaviors, providers are in a unique position to report on the personal, interprofessional, organizational, and system-level factors that impact delivery of respectful maternity care.

Consolidating evidence on provider perspectives on the full spectrum of childbirth care quality, ranging from obstetric violence to disrespectful and abusive care to respectful patient-centered care, is essential to addressing this gap. A review of literature on provider perspectives will facilitate the development of strategies to ensure that providers have the means and motivation to provide respectful maternity care.

2. Methods

This protocol used the Joanna Briggs Institute methodology for mixed-method systematic reviews [32]. A mixed-method review is well-suited to this subject matter because it allows for inclusion of varied study designs while retaining methodological rigor. A convergent segregated approach first synthesized quantitative and qualitative results separately, followed by an integration of all results. The study protocol was prospectively registered in PROSPERO (CRD42023477867). Findings follow guidance provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [33]. Quality was assessed using the Mixed Methods Appraisal Tool (MMAT) [34]. Appendix A lists the questions analyzed for the sixty studies.

Arksey and O’Malley’s methodological framework was used to conduct the review. The framework consists of five steps: 1) identification of the research question; 2) identification of relevant studies; 3) selection of studies; 4) data extraction; and 5) compilation, summary, and reporting of results [35].

Step 1: Identification of the Research Question

The questions guiding this review are:

1) How do maternity care providers practice disrespectful and respectful maternity care in facility-based birth?

2) How do maternity care providers perceive disrespectful and respectful maternity care in facility-based birth?

Step 2: Identification of Relevant Studies

Inclusion Criteria. The Population-Concept-Context (PCC) framework guided the inclusion and exclusion criteria, detailed in Table 1.

Table 1. Inclusion and exclusion criteria.

Search Strategy. The research strategy focused on the search for peer-reviewed publications. Primary quantitative and qualitative research studies of any type were included to focus on recent research. Articles from January 1, 2014 through July 1, 2024 were eligible.

Electronic databases PubMed, CINAHL, HOLLIS (Harvard Medical Library), and Medline were searched. The search strategy (Appendix B) used Boolean operators to align with the PCC framework. The search strategy tool was modified according to specifications of each database.

Step 3: Study Selection

Studies were selected based on the inclusion criteria detailed above. Duplicate studies were removed by organizing the articles in EndNote citation manager software. In the first phase of selection, titles and abstracts were screened to identify eligibility. Full-text articles were then read to assess eligibility and inclusion in the review. The selection process for the studies is detailed in a PRISMA flow diagram below (Figure 1) [33].

Figure 1. PRISMA diagram showing the study selection process.

Step 4: Data Extraction

The following information was collected from each eligible study. Reference management software and Excel were used to organize the data extraction.

• Citation (Author, Year).

• Number and profession of participants.

• Geographical location of study.

• Study methods.

• Prevalence of witnessed/perpetrated disrespect or RMC.

• Predictors/drivers of D&A.

Step 5: Compiling, Summarizing and Reporting the Results

Quantitative studies were summarized with descriptive results in a table format. Qualitative findings were synthesized thematically using methodology detailed by Thomas and Harden [36]. The results sections of selected papers were coded in Dedoose version 9.0.107 (stage one); descriptive themes were developed from the codes (stage two); and analytical themes were developed (stage three).

3. Results

The search identified 60 studies eligible for inclusion: 15 quantitative studies, 39 qualitative studies, and 6 mixed-method studies [37]-[98]. Of these, 36 were from Africa [37] [39] [41] [42] [51]-[55] [57] [59]-[61] [63]-[70] [72] [73] [75]-[79] [82]-[85] [88] [90]-[92] [96], 1 from East Asia [47], 2 from North America [50] [63], 4 from South America/Caribbean [81] [89] [93] [98], 3 from Europe [58] [80] [86], 6 from South Asia [43] [44] [71] [87] [94] [95], 4 from the Middle East [38] [46] [49] [74], 1 from Australia [48], 1 from both South Asia and the Middle East [45], and 2 global studies. Three studies also focused on the impact of COVID-19 [40] [56] [58]. Study participants included midwives, physicians, clinical officers, nurses, health officers, nursing/midwifery students, as well as clinical support staff and doulas.

3.1. Quantitative Study Results

Table 2 summarizes the quantitative study results.

Table 2. Summary of studies with quantitative components.

*Three articles report the results of the same study.

3.2. Qualitative Synthesis Results

Four themes emerged from the qualitative papers’ results: 1—facility issues, 2—hierarchy and control, 3—(mis)understanding and interpreting the mother’s experience, and 4—clinician responsibilities.

3.3. Facility and Structural Issues

Qualitative studies nearly universally identified poor staffing and corresponding high workload as a major barrier to providing respectful care [24] [37] [40] [52] [54] [58]-[71] [73] [76].

Providers noted two ways that high workload leads to disrespect. First, it makes providers less available to birthing people as patients. With many patients and competing priorities, it can be impossible to attend to all of them. One provider recounts:

“If you are dealing with three patients and one has eclampsia, another needs a caesarean section and the third suddenly has a hemorrhage, for sure one will be abandoned.”—Midwife, Mozambique [68]

Second, it adds to their stress, which in turn makes them less responsive to mothers’ needs. Providers reported lashing out at patients because of burnout and compassion fatigue.

“Whenever there is burnout then you just find yourself not giving the clients the best that you should, you just find yourself treating the patients as if they are the cause of the burnout.”—Clinician, Kenya [77]

Facility infrastructure presented an additional barrier. Facilities may lack sufficient supplies and have limited bed space, which was especially common in lower-income countries [54] [60] [61] [63] [64] [70] [72] [76] [78]. Even as some of these countries, including Ghana and Kenya, endorse a policy of free maternity care, patients of these hospitals are expected to bring their own supplies such as sheets or sanitizer. Clinicians reported that patients who did not bring these supplies evoked provider frustration and were sometimes scolded [37] [60] [77]. Lack of proper equipment constrains the options for different birthing positions, while lack of space makes privacy impossible and prevents the presence of birth companions [65] [68] [78] [79].

“Some women ask for their husband. But we cannot let them enter because we only have one corridor. Women walk half-naked and have contractions in the corridor. A man cannot see all that.”—Midwife, Mozambique [68]

The COVID-19 pandemic exacerbated facility constraints. Protocols disallowed visitors, masking hindered communication, and infection control measures took time from an already overburdened staff [40] [58]. COVID restrictions also limited interactions between mother and infants, in the case of preterm delivery, or if the mother tested positive for COVID [58]. Providers also acknowledged the relationship between these restrictions and potential poor outcomes for newborns and the long-lasting effects on partners, due to their inability to support both the mother and infant [58].

“We have less information regarding the protocols, which are still changing. Different protocols in different areas: for example, in the emergency room if clients do not have COVID-19 symptoms, service providers do not use a gown or screen, in the maternity ward they do.”—Midwife, Spain [80]

“Like I say, we’ve got lots of incidences where we’ve got women in and they’re going to end up being in five days and their partner can’t see them. Now that’s a huge chunk of life, and it’s really traumatizing for a lot of the partners.”—Midwife, UK [58]

The designation of some facilities as teaching hospitals, with staff-in-training being a part of routine care, was also mentioned as another characteristic that worsened maternity care [64].

“Yeah, women feel disrespected due to the teaching environment that leads to too frequent vaginal examination that is performed less than 4 hours apart. However, vaginal examinations are recommended every hour during labor.”—Midwife, Ethiopia [64]

3.4. Clinician’s Responsibilities

Providers’ responsibilities are multifaceted: they aimed to provide respectful, continuous care and emotional support, support family involvement, counsel their patients, and complete administrative tasks. Specialized roles, such as doulas, focus mainly on emotional and physical support of the birthing mother [81].

Responsibility to provide respectful care.

Many providers demonstrated knowledge of the ethical principles of respectful maternity care. In addition to rights-based ethical concepts like bodily autonomy and informed consent, they noted the importance of privacy, communication, and polite interactions. Providers denounced disrespectful and abusive care. They noted that poor experience in facility-based birth erodes trust in the health care system and indirectly contributes to maternal and infant mortality [82]. Abusive care was perceived as a violation not only of professional ethics but also of personal moral responsibility:

“It is unethical [to withhold care]. How would you sleep at night peacefully after abandoning a laboring mother?”—Midwife, Ethiopia [69]

“In my understanding, this should sound bad like beating a pregnant woman. She is in pain and this pain is observed even from her appearance. So, I think we cannot cause harm to her, like shouting on her, even beating her. This is against the midwives’ practices.”—Midwife, Rwanda [83]

However, even as mistreatment was denounced on its face, the perceived line between acceptable and unacceptable actions differed depending on the individual respondent and the different global cultural contexts within which they operate. For example, one physician believed that physical abuse was unacceptable, but verbal abuse could be justified:

“You can effectively yell, but don’t hit. When you can yell, is only if the woman closes her legs when she is in complete [cervical] dilation.”—Doctor, Guinea [76]

Providers’ awareness of the principles of respectful maternity care did not guarantee its practice.

“If we want to do anything for them, we obtain a consent, informed consent, we inform about the procedure and respectful ask for their consent whether they want the procedure to be performed on them especially vaginal examinations, we explain the procedure. I’m not saying that is what we practice but that is how it is supposed to be because by the time we have like 4 or 5 patients to attend to and you will want to use 4 or 5 minutes to counsel a patient you know time is fast spent.”—Midwife, Nigeria [84]

Responsibility to ensure survival.

Even as providers valued respectful care, they believed it could conflict with ultimate responsibility to ensure their patients’ survival. Delivering respectful care was secondary to safety, especially as providers grapple with the need to ensure the survival of not one but two patients—mother and baby.

“We are not doing this to harm the mother but to save the life of the baby.”—Support Staff, Kenya [85]

Abuse could be perceived as justified if the provider believed it was being done to “encourage” a patient or save the baby [60]-[62] [64] [67]-[69] [73]. This reasoning was used to justify verbal abuse, physical abuse, or threats:

“I mean, sometimes you’ve got to be a little rough … We’re not really supposed to, but sometimes that’s what you got to tell them … ‘If you do this, if you leave against our medical advice, your baby’s going to die’.”—Nurse, United States [62]

“Myself and a few of my colleagues at our workplace are nicknamed commandos because when we are on shift, we never end up with birth asphyxia. We are very tough with women during labour. If women fail to collaborate, they could be slapped, pressure applied to rescue her life and that of a child.”—Midwife, Tanzania [61]

“Women don’t know why we scream sometimes. We’re all shouting at them to save their lives and the unborn baby… but they don’t understand us.”—Midwife, Ethiopia [67]

Consequences of failing responsibilities.

The risk of maternal and fetal mortality weighs heavily on providers, not only for their patients’ sake but also for their own: providers face social and professional consequences if their patients die [54] [61] [68] [69] [73] [86]. Midwives especially noted how blame for death fell differentially on them, especially when compared to doctors [54] [68] [69] [73].

“When I look back to when I would always stick with the protocols and all the time refer to the obstetrician, well that was not because I thought that it was the best thing for mother and child. […] It was because… because I don’t know how it ends either. And if it doesn’t end well, I hang. I hang.”—Midwife, Netherlands [86]

“The women don’t cooperate, they refuse to bear and some will be like they are tired and if you are tired the baby will die and if the baby dies they will be like, the midwife has killed my baby.”—Midwifery student, Ghana [73]

Contributing to or witnessing the mistreatment of birthing people, even unintentionally and/or when constrained by policies, negatively impacts their job satisfaction and causes moral distress.

“Our staffing was so cr*p we were really almost working at absolute minimum care, certainly on the postnatal wards […] sounds awful and it is, and it was, you know, you’d come home from the shift crying.”—Midwife, UK [58]

“I get a sense of disappointment as though the system has failed this young woman [the patient].”—Midwife, Jamaica [75]

3.5. Hierarchy and power

Societal hierarchy.

Providers acknowledged that bias and preferential treatment at the birthing person’s bedside mirror larger societal inequities. Many reported particular frustrations with and subsequent disrespect for social groups with barriers to health literacy (such as those in poverty, with low literacy, first-time mothers, and younger people), who were perceived to lack knowledge of childbirth [74] [75] [87]. Differential treatment of racial and ethnic groups was another common theme. Birthing people of higher socioeconomic status tended to be treated better [37] [54] [62] [65] [70] [73] [77] [87] [88].Facility policies such as detaining birthing people in facilities if they are unable to pay [37] [54] [65] or mandating drug screens for those who miss appointments only exacerbated bias against vulnerable groups [62].

“She will have to listen to a lot of comments if she is poor. There is a lot of ignorance too. If someone is rich or from better income society, then every staff behaves very patiently, and respectful maternity care pours out of them. They know how to do it, just depends on whether you are worthy of respect.”—Nursing/midwife leader, India [87]

Birthing people who were language-discordant with their provider were also treated poorly, which was sometimes attributed to poor provider behavior and other times attributed to an inherent lack of clear communication due to the language barrier [51] [58] [62] [66] [70] [73] [86] [99].

“Those [non-English-speaking patients] require more work. And it’s not that it’s difficult work. But when your staffing ratios are terrible, it’s harder...it’s a time-suck. And you have other patients.”—Nurse, United States [62]

“She was so scared, and I said to the midwife, ‘I know it’s evening, but can’t we get an interpreter to translate?’ [...] But the midwife said, ‘You know, just do it’. And then I said, ‘But she doesn’t understand it.’ You know, I’m not going to just put my fingers in someone, while someone doesn’t understand, I think just really that that is a form of rape. I notice that when people are foreign and do not speak Dutch, they also use the opportunity to just do it, to let the student practice more.”—Midwife, Netherlands [86]

Some providers frowned upon traditional birthing customs, including the use of uncertified birth attendants or traditional herbs [37] [79]. The global power dynamics of Western medicine over other traditions plays out in facility-based births, according to one African provider:

“I work as I was trained. (…) I take the medical training that I received is of European norms and principles. So, we take that understanding expecting mothers who has come to the hospital for treatment or childbirth has left her traditions and customs at home. She has agreed with European norms.”—Skilled health personnel, Tanzania [79]

A few clinicians ascribed poor treatment of birthing people in childbirth to the poor status of women in society [80] [82] [87].

“Globally, women are of low status, not treated with respect or regarded as equal citizens, not valued. Little girls grow up thinking she is not as important as her brother, not likely to get educated, not encouraged to question. Women accept their lower place in the society. When they come to give birth, many of them did not choose to be pregnant, they did not have access to birth control. Married off very young. Arranged marriages, child brides. These all take away their empowerment. You find it difficult to stand up for yourself. When she is in labour, the last thing you want is fighting for yourself. You are so caught up in the psychological process that is happening, that makes you vulnerable as well.”—Nursing/midwife leader, India [87]

“[B]irth is a reflection of how society perceives women and until society respects women, I don’t think that we’re going to see a change.”—Midwife, Australia [89]

Interprofessional hierarchy.

Midwives in particular noted negative impacts of being in “the lowest rank in the hospital” [68]: they reported being blamed for negative patient outcomes and disrespected by patients and doctors [34] [60] [68] [69]. In contexts where men are more represented in higher-ranking positions (doctors) and women are more represented in lower-ranking provider positions, interprofessional hierarchy can intersect with gender hierarchy [68] [87].

“[The patients] might just slap or scratch you when you are working. You think they would do the same to a man? I don’t think so. It is just because we are women.”—Midwife, Mozambique [68]

“One time, nurses and midwives were being held as witches. It’s like a trail of under-representation that leads to disrespect and abuse of women and midwives. This increased in the 80’s and 90’s as the male medical model marginalised midwives.”—Nurse/Midwife leader, India [87]

Ranking of professionals (by seniority, academic rank, and leadership position within the department) can also be a barrier to respectful maternity care. Younger clinicians often lack the power to challenge disrespectful senior clinicians or facility cultures [61] [68] [75] [87] [89]. One midwife leader observed how a high-ranked abusive clinician can shift an entire organizational culture to one of normative abuse:

“It’s like a ripple in the pond. You have got an abusive person at the centre of that (…) The person at the centre becomes powerful and in order to maintain that power builds relationships and slowly people change their behaviour to fit into that way of being. The longer that person is able to stay in one place (centre) the culture (of abuse) grows stronger.”—Nurse/Midwife leader, India [87]

Conversely, hierarchy can also facilitate respectful care. The presence of a respected senior clinician provides accountability that prevents disrespectful care [66] [68] [90]. However, midwifery leaders cautioned against leveraging professional hierarchy in a punitive manner against providers, for instance, by blaming providers-in-training as they learn about respectful care. They noted that this does not address root causes of disrespect, such as facility limitations [87].

Clinician-patient hierarchy.

Clinicians expressed an expectation of control over the birthing process. Some providers believed that their clinical expertise could override the mother’s agency and embodied knowledge.

“I am the professional and I am the only right person to decide on procedures. What do the woman, or her family know about the care that I ask them for a consent?”—Midwife, Ethiopia [69]

Birth position was cited frequently as a variable that should be under the control of the provider rather than the birthing person [51] [59] [69] [79] [88] [91].

“Maybe she is used to squatting, sometimes they do squat, she tells you, I am used to delivering while squatting and maybe you want her to lie on the beds available so she can’t squat. And if you tell her she resists, so it forces you to be harsh for her to lie in the position you can manage to support the baby...”—Nurse, Kenya [91]

Even though providers expected a certain degree of control, they sometimes seemed to perceive a lack of agency on their own part: some reported that they “lost control” [68] or were “forced” to abuse their patients [77] [78].

The power dynamics present in delivery rooms are complex. Different levels of hierarchies intersect in the context of a facility-based delivery. For example, clinicians reported awareness of patient social status. Some felt that higher-status patients looked down on them as care providers and used disrespect to exert their clinician-patient power [69]. Others reported being on their best behavior when attending to well-educated patients [77]. In many cases, patients of more vulnerable status may be subject to more disrespect by clinicians. However, in some cases, a patient’s vulnerable status may elicit greater compassion from providers. According to one nurse:

“…This disabled mother or this the poor mother, the rich one, all of them… there’s that what we call equality and there’s that what we call first come first served. You can’t abandon the, or you can’t ignore the poor mother or the disabled and you run for the woman who has a car.”—Nurse, Kenya [91]

3.6. (Mis)understanding and Interpreting the Mother’s Experience

Clinicians perceived and/or assumed the delivery of a healthy baby to be the birthing person’s top priority. Accordingly, they justified mistreatment if they believed it ensured a birthing person’s “cooperation” and baby’s safety. In some cultural contexts, providers and birthing people alike may perceive disrespectful care as a necessary or normal means to a safe delivery [61] [68] [84].

Interestingly, some clinicians who were also mothers reported their own experiences of disrespectful care during childbirth [65].

“During my labour, the midwife insulted me, my junior. Even I myself, when I went into labour, I was beaten. They hit my thighs multiple times.”—Midwife, Kenya [92]

Laboring birthing people were expected to comply in a specific way, based on a particular society’s norms and culture. In some hospitals, they may be expected to bring their own delivery supplies, arrive well-groomed, and remain compliant throughout delivery. If a birthing person does not comply, staff may perceive her as intentionally troublesome [65].

Perception of the effect of labor pain on birthing persons, and the correct response from care providers, varied. Some believed that a birthing person in pain necessitated a harsher approach [78]

“...You know some mothers are uncooperative because of the pain […] if you are so gentle and so you can find some of them even injuring the baby so you have to be ‘firm’...”—Nurse-Midwife, Kenya [78]

Other times, they acknowledged that labor pain makes polite compliance difficult for the birthing person and her “misbehavior” is unintentional [51] [84]. Treating a birthing person in pain, therefore, called for extra patience:

“Most times, a woman in labour tends to get angry, insulting and can be aggressive. You tend to talk to them on a softer tone and don’t get offended with whatever you feel they are saying, respect their wishes.”—Midwife, Nigeria [84]

In the event of proper and effective provider-patient communication, however, it was possible to establish rapport, which led to a better experience for the birthing person [67] [69] [93].

“Humanization of childbirth takes place when you know the pregnant woman’s expectations, when you allow them to express themselves, to scream if they think it is going to relieve. She can choose her position and not be stuck on the bed. It is to know how she wants the delivery to be, if she wants to give birth sitting or in another way, she has to choose, it is not up to us, as professionals, to decide on that.”—Nurse, Brazil [93]

3.7. Integrated Summary

Like the variation in perspectives on different attributes of facility-based birth, the quantitative studies included in this review yielded a wide range of prevalence data. For example, one study in Kenya suggested that 53% of respondents witnessed and 45% perpetrated verbal abuse, compared to 37% and 35% for witnessing and perpetrating physical abuse [37]. A study located in Zambia suggested prevalence for D&A to be approximately 40.1% and 68.7% for perpetration and witnessing of D&A, respectively [52]. Another study in Nigeria identified the witnessing of D&A at a much higher rate of 73.1% [54], and nurses and midwives in Tanzania reported that 96.1% of participants had performed at least one form of D&A [57]. Seeing as this data ranges anywhere from 30 to 96%, there remains a critical lack of measurement standardization. While many studies attempted to operationalize the variable of obstetric violence/disrespectful maternity care, some looked at it strictly through the lens of risk factors and positive appraisal, whereas others examined it through the lens of provider mental health [41] [42].

Privacy was the element of respectful care most commented upon. In Ethiopia, the most witnessed form of D&A was lack of privacy protection, and in Jordan, leaving birthing people exposed was also most commonly witnessed [94] [95]. Likewise, in Tanzania, not draping for vaginal exams and conducting deliveries and other medical examinations in the presence of excess staff or students was also commonly witnessed and reported [57]. In Netherlands, it was common to disregard a birthing person’s privacy for the benefit of training students and allowing them to “practice” when the birthing persons were foreign and did not speak Dutch [86].

Both quantitative and qualitative studies emphasized the impact of staffing and healthcare infrastructure on care provision. The majority of qualitative studies noted that poor resources were a major barrier to respectful care [24] [40] [52] [54] [58]-[76]. Quantitative studies also found negative relationships between respectful maternity care and organizational factors such as staffing and workload [38] [56] [57].

Differences in training also accounted for differences in provider knowledge of obstetric violence and disrespectful maternity care. In Kigali City, Rwanda, midwives at three different district hospitals shared that their curriculum was oriented around RMC, with orientation and internal regulation serving as training methods [83]. This education also ensured that midwives were aware of the rights of birthing people and what they were owed in healthcare settings [83]. Within the various types of providers, there were also different understandings of what constituted maternal rights and ethical practices, and whether certain behaviors were in violation or not. For example, in Ethiopia, some midwifery trainees and students reported that the focus of professional ethics in midwifery curriculum was mostly concerned with patient privacy and confidentiality [70]. In China, a longer training period, via either an internship or practicum, was associated with both a better understanding of RMC and fewer occurrences of disrespect and abuse [47]. However, in India, better-trained personnel were less likely to report observation of RMC at their facility [43].

Some studies contextualized disrespect and abuse as breaches of professional conduct and responsibilities, but also sometimes justified to save the birthing person or baby [69]. Other studies viewed disrespectful maternity care through the lens of humanization, while still others looked specifically at one type of provider (such as charge midwives) and explored their perceived role in improving RMC [90] [93].

The role of organizational and professional hierarchy and accountability appears differently in quantitative and qualitative studies. For example, in Rwanda, healthcare providers in five different hospitals described internal policies to manage cases of disrespect and abuse; approaches ranged from appointing a team leader, to reassigning specific staff members if problems arise to the use of a “quality book” to keep track of staff infractions [96]. In quantitative terms, professional and organizational hierarchy/accountability was used as a statistical predictor and driver. For example, positive relationships with facility managers and team leaders were significantly associated with increased RMC scores in Malawi [42].

Ultimately, the question of operationalizing RMC and understanding what supports and hinders it is best explored through quantitative and qualitative methodology. There is a wide variance in the reported prevalence of disrespect and abuse. Beyond measurement issues, this could be due to cultural differences in reporting norms or selection bias of the specific types of providers surveyed in the different studies. Across this large swath of research from every region of the world, there are notable consistencies between variables of importance, such as privacy, training, and hierarchy, that are framed and considered differently within the context of methodology. Thus, to produce effective solutions for disrespectful maternity care, understanding how these variables can be measured and operationalized in multiple ways is crucial.

4. Discussion

This review’s focus on provider perspectives allows for deeper examination of dynamics outside of the birthing person-provider dyad; providers report personal, interprofessional, organizational, and system-level factors that impact delivery of respectful maternity care.

The plurality of studies focused on Sub-Saharan Africa [41] [42] [48] [51]-[55] [57] [59]-[61] [63]-[70] [73] [76] [78] [79] [82]-[85] [88] [90] [91] [95]-[98]. This is a priority region in global health due to its high maternal mortality ratio (545 maternal deaths per 100,000 live births in 2020) [6]. There is a relative dearth of research in higher-income countries, with only three from Europe [58] [80] [86] and two from North America [50] [62]. The lack of research in North America is notable, given that it is the only region in which the maternal mortality ratio has increased since 2000 [6]. The important implications of this gap may be directly related to emerging challenges for obstetrical care in North America.

4.1. Strengths and Limitations

One limitation of this review is the possible exclusion of relevant articles due to lack of consistent terminology used to describe the continuum of respectful and disrespectful care. The language limitation of English-only articles is also exclusionary, given the fact that much of the research happening in this field is globally located. It is likely that social desirability bias may also influence the results of the included studies. This review focused on intrapartum care. While this period is one of unique vulnerability that is not found at other timepoints in the maternity care continuum, such focus may overlook the ways that disrespect and abuse may manifest and perhaps originate in antenatal care. Additionally, the obstetrical training, work demands, and work-related stressors of birthing providers may vary by region and the socioeconomic and medical infrastructures of different countries. These differences may require interventions to improve respectful maternity care to be tailored to the specific country.

A strength of this review is that it aims to cover the full spectrum of care quality, both positive and negative. Thematic synthesis will allow for a fresh interpretation of both the qualitative and quantitative evidence. Ultimately, this review equips policymakers and healthcare providers with the insights needed to design and implement targeted interventions that improve the quality of maternity care and ensure respectful treatment for all patients.

4.2. Complexities of Defining Disrespectful Maternity Care

Due to the many different frameworks and definitions used to understand disrespectful maternity care, there are more qualitative than quantitative studies in this field. This lack of standardization and operationalization often stems from cultural variations, differing healthcare practices, and the subjective nature of what constitutes disrespect. Additionally, disparities in resources, training, and awareness among healthcare institutions contribute to the inconsistent recognition and documentation of disrespectful behaviors, as each clinical site in this review is differently staffed and structured.

The absence of standardized measures for disrespectful maternity care necessitates an integrated methods approach to synthesizing providers’ perspectives. By employing an integrated methods approach, combining qualitative and quantitative data, researchers can capture the nuanced experiences and attitudes of providers, leading to more effective interventions and policy development aimed at improving maternity care standards universally. Without such an approach, the pervasiveness of disrespectful maternity care will continue alongside its obscureness; a problem becomes easier to ignore when it is ill-defined.

Inconsistencies in metrics and the operationalization of respectful and disrespectful maternity care mirror the broader challenges in defining and measuring other metrics in maternal health. Both areas suffer from a lack of standardized definitions and criteria, influenced by varying cultural, social, and institutional contexts. Just as respectful and disrespectful care can be subjective and context-dependent, maternal mortality definitions can differ based on what is included in maternal death statistics—such as indirect causes or timeframes post-delivery.

The development of valid quantitative measurement tools is an emerging area of research in this field. This review found that many studies had a descriptive element that focused on categorizing types of respectful and disrespectful care [43] [44] [47]-[52] [57] [85] [94] [95]. This echoes earlier research and frameworks, such as the landscape analysis by Bowser and Hill (2010) [25]. Others go beyond description to examine barriers and facilitators to respectful care. This recalls the work of researchers such as Bradley et al. (2019) [100], Behruzi et al. (2013) [101], and Sadler et al. (2016) [102], who expanded beyond earlier descriptive frameworks to incorporate organizational and society-level factors that address structural dimensions of respectful maternity care.

4.3. Recommendations

This review may aid in identifying points of intervention. Currently, fragmented systems and inflexible policies dominate this landscape. Using this systematic analysis of diverse contexts and healthcare systems could help pinpoint the healthcare processes that subject birthing people to increased vulnerabilities, disrespect, and harm [89]. Recommendations are summarized in Table 3.

Table 3. Recommendations to improve respectful maternity care.

The complexity of this issue necessitates a multifaceted response. There is no one way to define or capture all the ways in which disrespectful maternity care prevails, especially when factoring in the global differences in healthcare system resources and provider roles. Thus, training health care providers within a specific site’s context is a common intervention strategy. A review of educational interventions to improve RMC found low-level evidence that educating providers can improve their knowledge of and attitudes toward RMC [103]. Team simulation training and collaborative workshops can also improve the quality of patient-provider communication [75] [104] [105]. However, while staff training may improve respectful maternity care to some degree, it is hardly a singular cure-all. Several studies in this review revealed a gap between provider’s knowledge of respectful maternity care and its practice [84]. This gap is a critical barrier and future interventions should move beyond simple education to focus on implementation science and identification of systemic obstacles to practice. Multi-pronged interventions (e.g., a combination of childbirth education for parents and RMC training for providers) appear more promising than staff training alone [106].

Resource-driven factors such as staffing, workforce development, hospital design, and medical supplies also act as barriers to RMC. Interventions focused on leadership, supportive supervision, peer support, and anticipated planning for staffing shortages may reduce the impact of resource limitations within an organization [107]. At the same time, the impact of medical and professional hierarchies cannot be overlooked: studies suggest that entrenched power structures can exacerbate resource and organizational issues. Workforce development, therefore, should not only consider staffing needs but also the redesign of existing power hierarchies via transformed leadership policies and approaches. Interventions should target not only individual training but also institutional power structures. This could be accomplished through formalized mentorship programs and safe, anonymous reporting systems for junior staff.

Policy and legislation are other avenues to address disrespectful care. South American legislation is notable in its criminalization of obstetric violence. Addressing health care provider accountability through legislation cannot be undertaken without an understanding—and perhaps questioning—of the ingrained norms and hierarchies that govern the context of facility-based birth. Societal norms that value women primarily for their reproductive function are reflected in laws that prioritize fetal protection over birthing people’s autonomy [108]. Any measures, especially punitive legislative measures, that aim to hold providers accountable for fetal safety, along with maternal safety and autonomy, must consider the complexity of the provider’s obligations to the unique two-patient dyad. Any measures that take a rights-based approach to emphasize the importance of consent in maternal care must consider the inherent power imbalance between providers and patients. Some feminist scholars have questioned the possibility of true consent in the setting of such an entrenched hierarchy [99].

5. Conclusion

While the manifestations of disrespectful care differ across the world, the need for a greater understanding of respectful maternity care transcends borders. Researchers have advocated for a universal set of clinical guidelines to offer interventions at the ideal time, while prioritizing and respecting birthing people’s rights [72]. Furthermore, the global reach of D&A offers opportunity for care models to be referenced around the world.

Availability of Data and Material

The data underlying this article will be shared upon reasonable request to the corresponding author.

Funding

This work was supported by the Massachusetts General Hospital endowed Global Health Fund—Strength & Serenity, fund number 1200 020707.

Authors’ Contributions

The design and literature search were carried out by KDF. Screening, analysis and synthesis were done by KDF and SN. Substantive revisions were performed by MG and AG.

Abbreviations

Appendix A: Mixed Methods Appraisal Tool (MMAT)

From: [34].

Appendix B

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References