Table 1 shows the distribution of the socio-professional characteristics of healthcare professionals surveyed.

The mean age of participants was 38.1 ± 9.4 years, with a range from 22 to 61 years. The most common age groups were 25 - 35 and 35 - 45, each representing 31.2% of the sample.

The majority of participants were female (79.2%), with a sex ratio of 0.26 (male/female). In terms of professional category, 77.1% of respondents were midwives, and 22.9% were obstetrician-gynaecologists. The majority of participants had between 10 and 20 years of professional experience.

The majority (93.8%) of healthcare professionals surveyed had already heard of respectful maternity care, and 72.9% of participants had already received training on respectful maternity care, including 35.4% during their initial training (school) and 37.5% during continuing education.

Of the healthcare professionals, 93.8% understood its main objective. Regarding the WRA Charter for Respectful Maternity Care, 41.7% were unable to specifically name the number of categories of rights.

The key principles of respectful maternity care, such as confidentiality, autonomy, and informed consent, were understood by 79.2% of participants, and 91.7% recognized the importance of respecting women’s dignity in the charter. Furthermore, 97.9% of respondents emphasized the value of respectful communication in the care relationship. Finally, 97.9% of participants stated that the application of the principles of the WRA Charter promotes a positive and respectful birth experience, and 83.3% had well integrated the concept of non-discrimination, emphasizing the importance of equal treatment for all women.

Figure 1 shows the overall knowledge levels of healthcare professionals regarding SMR.

It appears that 45.8% of participants had an insufficient level of knowledge, constituting the largest group.

Table 2 shows the distribution disrespect or abuse observed in delivery rooms.

Refusal to have an accompanying person present during labor and delivery was the most common incident. 20.2% of patients underwent an episiotomy without anesthesia, 14.4% of patients had their medical information discussed within earshot of other patients (non-confidential care), and 6.7% of patients were subjected to shouting by healthcare staff (undignified care).

It was noted that 100% of patients experienced abandonment or refusal of care, constituting the largest category of inappropriate practices. In comparison, 22.1% of patients were victims of physical violence. Non-confidential care and non-consensual care affected 14.4% and 12.5% of patients, respectively, while 10.6% of practices constituted undignified care.

In our study, the average age of healthcare professionals was 38.1 years, ranging from 22 to 61 years. The most represented age groups were (25 - 35) and (35 - 45), each constituting 31.2% of the sample. These figures are similar to those of Aguemon et al. (Benin), who found an average age of 39.44 years [7] . Shimoda et al. (Tanzania) and Uwamahoro et al. (Rwanda) had average ages of 33.9 in 2018 and 31.3 in 2023, respectively [8] [9] .

The majority of healthcare professionals in our study had between 10 and 20 years of professional experience (37.5%). In Benin in 2022, Aguemon et al. reported a 50% incidence of healthcare professionals with more than 10 years of experience [7] .

According to a study conducted in Tanzania in 2018, the average number of years of professional experience was 7.7 years [8] .

This situation can be explained by the fact that the study centers are reference hospitals, where expertise is crucial.

In our study, no healthcare professional’s level of knowledge was rated as good. Indeed, only 39.6% of healthcare professionals had an average level of knowledge. In other words, more than 60% have a poor or insufficient level of knowledge. This seems paradoxical considering that 72.9% of staff reported having been trained. Several reasons could explain this situation: an oversight (35.4% during their initial training (school), a lack of interest among participants in continuing training or a purely financial motivation. This highlights the need to review the ways to promote RMS among healthcare professionals.

In their study, Aguemon et al. reported that the majority of healthcare professionals had a poor level (83.33%) [7] . A study conducted by Mirzania et al. in Iran in 2021 also reported a high frequency of healthcare professionals with a poor level of knowledge (82.7%) [10] .

This difference in level could be related to the presence of physicians in our sample, which contributes to improving the overall level of knowledge, unlike other studies that only considered midwives.

Our study revealed that all women experienced at least one form of disrespect or abuse, resulting in a zero prevalence (0%) of SMR. Many authors around the world have reported figures similar to ours. These include Bigot et al. in Benin in 2023 (0%) [11] , Adinew et al. in Ethiopia in 2021 (0%) [12] , and Okafor et al. in Nigeria in 2015 (2%) [13] . Other authors have found a higher prevalence of SMR. In Ethiopia, Bekele et al. in Ethiopia in 2020 reported a prevalence of 21.8% [14] , comparable to the result of Usso et al. in 2023 in the same country with a prevalence of 23% of SMR. This difference can be explained by the difference in the study method, with our study being much more objective, observational, as opposed to the method used in these studies, which relied exclusively on women’s own statements.

Physical violence was observed in 21.1% of women in our study, with the majority of women having undergone episiotomies without anesthesia (20.2%). These results are similar to those obtained in Ethiopia by Anteneh et al. in 2018 (25.9%), Bekele et al. in 2020 (21.5%) [14] , and Usso et al. in 2023 [15] (26.8%), with the difference that in these cases, the women were mostly tied up, beaten, or slapped. On the other hand, the high frequency of 88.44% of physical violence reported by Atade et al. in the North of Benin in 2021 [16] , suggests a greater presence of physical violence at the peripheral level of the Beninese health pyramid.

During our study, free and informed consent was obtained from 87.5% of women. Only 10.5% of women were not encouraged to ask questions about their medical conditions. In Ethiopia, Usso et al. also reported in 2023 that 16.2% of women were not encouraged to ask questions. [15] . However, these results are contrary to those of other authors who have reported a low prevalence of consented care [15] [17] [18] . The data collection and evaluation method, particularly the observation effect, may lead professionals to modify their behaviors in order to move towards norms; this potentially implies additional effort in requesting consent.

No patient was allowed to have a support person during labor and delivery during our study. Kwame et al. reported a similar situation in Ghana in 2022 [19] . The presence of a support person is recommended by the WHO in its guidelines on intrapartum care for a positive childbirth experience [20] . Respecting this right remains difficult due to the configuration of delivery rooms and the lack of human resources. Indeed, these are most often common rooms or, at best, adjoining cubicles, but not private rooms for the women in labor. The need for a level of asepsis to prevent maternal and neonatal infections, to protect the privacy of the women present, and to allow the often reduced staff to monitor several women in labor at once explains this situation.

Confidentiality was observed with a prevalence of 85.6% during our study. The violation observed in this category was the discussion of a patient’s information within earshot of other patients. These results are similar to those reported by Aguemon et al. and Bigot et al., who found a respective prevalence of confidential care of 88.58% and 91.2% in Benin. Ukke et al. in Ethiopia in 2019 and Atai et al. in Kenya in 2018 also reported high prevalences of 82.9% and 78%, respectively [21] [22] . This prevalence of confidentiality could be linked to the growing awareness among healthcare professionals of the need to respect the confidentiality of patient information. Furthermore, the boxes, when they exist, offer professionals the opportunity to respect confidentiality.

During our study, 89.4% of women received maternal care with respect and dignity. Disrespectful acts were observed in 10.6% of cases and included yelling at the patient (6.7%), not greeting the patient respectfully (2.9%), and mocking the patient (1%).

These observed acts of disrespect can be explained by emergency situations during which healthcare professionals may raise their voices to ensure the survival of the mother and baby and avoid serious complications that could arise.

The prevalence of respect for this right in our study was 100%. These results are similar to those reported by Usso et al. [15] in Ethiopia in 2023 (94.5%). Aguemon et al. in 2022 [7] found a prevalence of 94.74%.

These high prevalences may be explained by the difficulty of assessing this aspect, which can be subtle; discrimination can take forms that are difficult to identify, especially in our case where the observation was of short duration.