Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Abstract

Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee-exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC.

Unveiling respectful maternity care as a way to address global inequities in maternal health

“…Here, I am largely drawing from an implementation research from Ethiopia that explored health system constraints to the promotion of RMC in public hospitals and tested a multicomponent intervention (staff training, placement of wall posters and post-training onsite support for quality improvement) that was designed to promote RMC. [18][19][20] The study used an interventional mixed methods design that included surveys of both women and service providers before and after the intervention, focus group discussions with service providers before and after the intervention and in-depth interviews with key informants before the intervention. Based on the findings of the study and other implementation studies from Kenya, Nigeria and Tanzania, [21][22][23] I have synthesised approaches to the promotion of RMC (figure 1).…”

“…Given the complex relationships between different elements described in figure 1, 18 RMC interventions targeting a specific component cannot have a lasting effect. In lieu, system-oriented and multidimensional interventions are warranted to improve the accessibility and uptake of maternity care and march towards BMJ Global Health a rights-based approach to ending maternal mortality.…”

The impact of COVID-19 on the provision of respectful maternity care: findings from a global survey of health workers

“…The entangled nature of the negative impacts of the COVID-19 pandemic on the provision of RMC indicates that these impacts should be addressed from a multidimensional health system strengthening perspective to ensure the sustainability of results 10 . Building local capacity to translate emerging evidence and global guidelines into context-adapted strategies is vital to ensure that essential services will be provided with little or no disruption of RMC 40 .…”

Midwives’ perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study

“…Midwives commonly reported verbal abuse, physical abuse, lack of visual privacy, poor record confidentiality, neglect, and non-dignified care [5,8,[22][23][24][25][26][27][28][29][30][31][32][33]. Disrespectful care of childbearing women results from lack of co-operation from women [8,22,23,26,31], lack of resources [5,22,23,28,29,34], midwives' normalisation of abuse [31], negative view of women [27,31], exertion of power and control over women [8,24,25,30,31], fear of being blamed for poor childbirth outcomes and medical necessity [5,8,22,23,26,31], high workload and tiredness [5,29,34], and use of moral judgement [24,35].…”

“…On supportive maternity care, midwives emphasised lack of labour and childbirth support [22,39]; inadequate staffing [22, 24, 28-30, 34, 36, 37, 40]; lack of equipment and materials [28][29][30]34]; poor motivation and lack of skills [29,34]; poor access to water [28]; crowded wards [22]; lack of bathrooms [29]; and negative hierarchical relationships with their superiors and doctors [25,28] as constraints to supportive maternity care in sub-Saharan Africa. Midwives restrict companions during labour and childbirth due to cultural unacceptability, staff or infrastructural constraints [25,37], negative attitude towards women's relatives [41] or women's objection to birth companions [22].…”