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

Abstract

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.

Exposing Obstetric Violence in the Eastern Mediterranean Region: A Review of Women's Narratives of Disrespect and Abuse in Childbirth

“…Due to the normalization of the culture of technocratic and overmedicalized care, it is likely that health workers are not even aware that they are perpetrating OV. This was confirmed in global literature citing that the chief barriers to improving RMC included provider attitudes, misconceptions of its definition and violations, and false beliefs that expectations are met ( 65 , 67 , 73 , 74 , 82 ). Zooming out more broadly, non-dignified care, and its intersections with other abuses is embedded in socio-cultural norms.…”

“…Similarly, women from Ethiopia and India ranked this type of D&A highest, possibly due to geographical and cultural proximity to the EMR ( 79 , 80 ). Global systematic reviews found a high prevalence of verbal abuse across the high, middle, and low-income countries, with threats and judgmental attitudes being more common in LMICs, while objectification of women's bodies was reported more in M/HICs ( 19 , 21 , 81 , 82 ).…”

“…While this framework is simple in its presentation, the list-format of the B&H model inhibits the conceptualization of the interconnectedness, compounding, and overlap of the types of abuses. The lack of standardized definitions of each type of D&A makes it even more difficult to compare systematically across studies, countries, and regions, particularly as various studies set their own definitions and sub-themes ( 6 , 7 , 19 , 21 , 27 , 28 , 82 ). While updated frameworks have expanded to explicitly capture sexual abuse, verbal abuse, legal, political, personal, health system, and socio-cultural factors affecting D&A, many still use list-format or more complex organization of themes ( 19 , 21 , 67 , 68 , 82 ).…”

“…The lack of standardized definitions of each type of D&A makes it even more difficult to compare systematically across studies, countries, and regions, particularly as various studies set their own definitions and sub-themes ( 6 , 7 , 19 , 21 , 27 , 28 , 82 ). While updated frameworks have expanded to explicitly capture sexual abuse, verbal abuse, legal, political, personal, health system, and socio-cultural factors affecting D&A, many still use list-format or more complex organization of themes ( 19 , 21 , 67 , 68 , 82 ). Finally, while the authors attempted to explain the intersectionality of the terms and concepts in Figure 2 , this study is also limited by the controversies in conceptualizations (e.g., mistreatment vs. dissatisfaction vs. OV vs. D&A) and inconsistencies in terminologies in a nascent topic in the empirical literature ( 2 , 6 , 10 , 19 – 23 , 78 , 90 ).…”

A qualitative inquiry into pregnant women’s perceptions of respectful maternity care during childbirth in Ibadan Metropolis, Nigeria

“…There has been no agreed global definition of RMC because it is not simply the absence of mistreatment, 10 and women’s voices should contribute to defining it. 11 The World Health Organization defines RMC as “care organised for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth”.…”