Midwives’ experience of respectful maternity care (RMC) globally: A meta-synthesis

Abstract

Background

Respectful maternity care (RMC) emphasizes the social and relational elements of maternity care and is a crucial part of initiatives to improve service accessibility and quality. Women's perceptions have influenced much of what we know about RMC and contempt in the labor ward. In order to understand midwives' perspectives of RMC, this meta-synthesis focused on them.

Method

For this inquiry, the databases PubMed/Medline, Embase, Web of Science, and Scopus were searched to find studies on midwives' perceptions of RMC written between 2011 and April 20^th 2023. The included articles were to English language restriction. The results of the included research were examined using thematic analysis. Using the inclusion criteria, 84 potentially relevant articles were carefully reviewed, and only 22 were ultimately selected for synthesis. The quality of the qualitative study was assessed using the CASP, a tool for quality evaluation and PRISMA guidelines were followed. Using the MAXQDA program, the cited quotes and the original authors' interpretations were combined.

Result

There were 22 studies total, thematic synthesis was determined to be appropriate for a total of 22 research studies. Following are the topics which we summarized our analysis: in six major themes: Midwives’ conceptualizations of RMC, Midwives commitment to woman’s rights, The value and impact of RMC to midwives, Midwife’s perception of disrespectful care, Challenges in providing respectful maternity care, and Midwives’ recommendations for optimal RMC practice.

Conclusion

In addition to specific focus on promoting cooperation, policies to enhance health systems and strategic consideration of the midwifery profession's future are required.

Keywords

Midwives’ experience disrespectful respectful care global meta-synthesis

Introduction

Respectful maternity care (RMC) emphasizes the social and relational elements of maternity care and is a crucial part of initiatives to improve service use and quality. It is based on a rights-based philosophy, which is encapsulated in the White Ribbon Alliance for Safe Motherhood's (WRA) Respectful Maternity Care Charter. The charter emphasizes women's entitlement to: freedom from discrimination, harm and mistreatment; provision of information, choice, consent, and companionship; care that respects and maintains women's dignity, privacy, and confidentiality; as well as autonomy and access to timely, quality healthcare.¹ The care provided to women after delivery is also categorized using a variety of additional terminology. “Humanized care” in Latin America often emphasizes de-medicalization and views childbirth as a common occurrence.² “Woman-centered care” is a concept that emphasizes holistic care that takes a woman's social, emotional, physical, psychological, spiritual, and cultural needs and expectations into account, for instance, in the United Kingdom and Australia.³ The majority of global initiatives to lower maternal mortality have focused on raising the percentage of women who give birth in a medical setting with a trained birth attendant. Regular disregard for the sociocultural and psych emotional significance of birth and its confluence with structural inequality expresses itself in actions that are seen as disrespectful and dehumanizing. Women being disrespected and abused (D&A) during giving birth is a serious worldwide public health concern. It includes a variety of actions that violate a woman's autonomy, culture, physical integrity, and dignity, as well as her human rights and constitute gender-based violence. Disrespected and abused affects the most vulnerable people disproportionately, including women who are poor, rural, disadvantaged, or subject to numerous oppressions. It also connects with other types of systemic violence and gender inequality. The movement to address D&A and guarantee women get RMC is gaining traction.⁴

A recent shift in focus away from a primarily technical focus on simply “what to do” has been described as a “radical turnaround” from what has been described as the international community's “blind spot” on the quality dimension of respectful, woman-centered care.⁵ This involves taking into account the non-clinical, social aspects of maternity care. The RMC campaign has gathered support. Following Latin American initiatives to apply a humanizing birthing perspective to stop the flow of widespread human rights violations of laboring women, there has been significant worldwide movement in recent years. The WRA's tenacious campaigning and the Charter on the Universal Rights of Childbearing Women have encouraged other organizations to take initiative and take action.¹ There have been a lot of significant events in recent years. The International Federation of Gynecology and Obstetrics (FIGO) criteria and indicators for Mother and Newborn Friendly Birthing Facilities (2015), the World Health Organization's (WHO) influential statement on the prevention and elimination of disrespect and abuse,⁶ and the high-profile, critical analysis of global midwifery in the Lancet Series on Midwifery⁴ and the latter two are particularly noteworthy. A variety of papers have also described the typologies and frequency of disrespectful acts during facility-based delivery).^7–9 A large number of the workplace issues that midwives face is also linked to the causes of D&A in maternity care. According to West, “the quality of patient care may be related in an important way to the quality of life experienced by staff at work.”¹⁰ Each of these acts as a deterrent to motivation, job happiness, and productivity. It is impossible to ignore how the institutional framework and the rude facility administration affect how health staff treat patients. There are serious questions to ask about how staff operating in such environments can be expected to behave in a different manner. There are important concerns to consider about how personnel working in these settings should be expected to act differently. The viewpoints of providers on RMC and D&AC have been the subject of several researches.^11–13 However, no research has been done on the viewpoints of the midwives ‘on disrespectful and respectful maternal care. Thus, the aim of this study was to compile and provide information from qualitative research about how midwives throughout the world felt about RMC. The study team utilized the data to guide the creation of a midwifery professional ethics program by policy marker to advance RMC.

Method

Eligibility criteria

To guarantee the accurate identification of relevant research, an inclusion criterion was created and defined using the SPIDER format. The SPIDER components used for this review are shown in Table 1. A comprehensive literature search of the qualifying research was conducted in the following databases to choose papers published between 2011 and April 20, 2023: Scopus, Embase, PubMed, Web of Science, and Cochrane.The search was restricted to commence from 2011. In 2011, the Respectful Maternity Care Charter: “The Universal Rights of Childbearing Women” was produced as a consequence of the White Ribbon Alliance's¹ worldwide effort to promote RMC as a fundamental human right. The included articles were to English language restriction.

Table 1.

Elements of the review inclusion according to the acronym SPIDER.

Elements of SPIDER	Elements of SPIDER as applied to this review
S - sample	Midwives, who have experienced or perspective or attitude of respectful maternity care (RMC) or disrespect and abuse care (D&AC)
PI - phenomenon of interest	Qualified midwives’ experiences or perspective or attitude of respectful maternity care (RMC) or disrespect and abuse care (D&AC)
D - design	Individual interviews and focus group discussions
E - evaluation	Experiences, views, perceptions, perspectives OR perspective OR opinion OR opinions OR attitude
R - research type	Primary qualitative research studies: Qualitative, qualitative exploratory, phenomenology approach, and mixed-methods strategy in which only the qualitative information was used

Search strategy

An initial search was conducted on PubMed, Web of science, Scopus, Embase, and Cochrane. The Faculty of Health Science librarian at the University of Ahvaz Jundishapoor medical science provided support with the database search.

“Nurse Midwives” OR “Nurse-Midwives” OR “Nurse-Midwife” OR “Nurse Midwife” OR Midwives OR midwife.

Perspectives OR perspective OR experience OR experiences OR Attitude OR Attitudes OR Sentiment OR Sentiments OR Opinion OR Opinions.

Respectful Maternity Care (RMC) OR Humanization OR humanized OR Human right OR Respect OR ethos OR ethic OR Dignify OR Disrespect OR Non dignify OR Dignity OR Non dignity OR Ignored OR Abuse OR mistreatment OR violence.

“Labor, Obstetric,” OR Obstetric Labor OR Labor OR Labor OR childbirth OR Childbirth OR Parturition OR Delivery AND Setting Maternity care (setting in any country). Search filters were used to restrict and only include research articles with publication dates between 2011 and 23 March 2023. Two reviewers (SH and MI) manually screened the article titles and abstracts according to the inclusion and exclusion criteria. There were no disagreements between the reviewers during the screening process. The Preferred Reporting Items for Systemic Reviews (PRISMA) flow chart (Figure 1) shows the results of articles that were included and excluded. The PRISMA ensures significant transparency in the selection method of papers in systematic reviews.¹⁴ Twenty-two studies were ultimately selected to be included in the review.

Figure 1.

PRISMA (2020) diagram for searching resources.

Quality appraisal

The Critical Appraisal Skills Programmer (CASP) is the tool most used by novice researchers for quality appraisal in health-related qualitative evidence syntheses to assess the quality of included studies.¹⁴ Three reviewers assessed each of the included studies independently (MI, SH, and SM). The studies were assessed for the clarity of the research aims, the research methodology and design, the recruitment strategy, data collection, reflexivity of the researchers, ethical considerations, data analysis, findings, and the research value. The items were scored with “yes,” “no,” and “can’t answer.” The study goals were clearly stated in each of the 22 included papers, and the qualitative technique and research design were suitable for addressing the goals of the research. The three reviewers reached an understanding via discussion that all research studies were relevant and ought to be included by the review. The GRADE CERQual technique, which permits the evaluation of how much confidence can be put in individual review results from a qualitative synthesis search, was used to rate individual review findings.

Data extraction

To record the standard components pertaining to the caliber and content of investigations, researchers use data abstraction forms. The year of publication, the nation of publishing, the design, the objective, the sample, the data collecting and analysis procedures, the research constraints, and the themes were all taken from each included study. MAXQDA software (version 2021) was used to import quotations and the main author's interpretations, which were then further examined utilizing open coding to create the categories. Themes were created by grouping and categorizing the preliminary codes in accordance with their meanings, similarities, and contrasts.

Data synthesis

The reviewers utilized a mixed inductive and deductive technique to analyze the data (SH is the researcher, and SM is the independent coder). The synthesis was carried out utilizing a theme synthesis in accordance with the recommendations of Thomas and Harden.¹⁵ In order to better fit the variety of newly emerging material, categories and subthemes were reorganized, quotations were tagged, and the thematic analysis approach was applied. Thematic synthesis includes creating descriptive and analytical themes from data that has been methodically coded.¹⁵ Each reviewer used MAXQDA software to code the text line by line according to its meaning and substance.¹⁶ By transferring ideas from one research to the next, they generated developing descriptive themes, which were then condensed to the major fundamental themes. Three reviewers (SH, SM, and MI) then had a virtual consensus discussion to assess the alignment of their findings and come to an understanding of the main themes. Everyone agreed that the themes accurately summarized the results of their research. The method of developing a topic is shown in Table 2. Using the GRADE CERQual methodology, it was also determined how much confidence might be put in each qualitative review result. The bulk of the research included in this study either used exclusively qualitative techniques or three mixed-methods strategy in which only the qualitative information was significant. In the relevant publications, we concentrated on and summarized the interviews with midwives.

Table 2.

Analytical themes and subthemes.

Theme	Subtheme	Sub-subtheme
Midwives’ conceptualizations of respectful maternity care	Treat mother with respect
	Respect for mother's autonomy and decision-making
	Preserving privacy and confidentiality
	Providing equal care	-Avoid from discriminating
	Women-centered care	-Obtaining consent to the procedure
		-Respect for choices and preferences
		-Women's individual care
		- Evidence-based care
Midwives' commitment to women’s rights	Midwives' awareness of respectful maternity care
	Midwives’ knowledge of respectful maternity care
	The attitudes of midwives toward respectful maternity care
	Midwives’ skills	-Empathy with mothers
		-Supportive care
		-Communication skill
The impact of respectful maternity care on midwives	Pride in their work
	Social benefit
	Religious beliefs
Midwife’s perception of disrespectful care	Midwife perception of caregiver abuse	-Internalized and normalized disrespected and abused care
	The violation of women-centered care	-Neglect and abandonment
		-Non-consented care
		-Discriminatory care
		-Uncooperative woman
		-Refusing to help women during labor
	Disconnect between awareness and practice of respectful maternity care
Challenges in providing respectful maternity care	Health system barriers	-Shortage of resources
		-Shortage of midwives
		-Lack of motivation,
		-Lack of providing timely care
	Hospital managerial rules
	Midwives’ position in the health system
	Midwives being disrespected by a coworker
	Need midwifery training on respectful maternity care
Midwives’ recommendations for optimal respectful maternity practice	Continuous training for improving respectful maternity care	-Enable midwives implement alternative birthing positions
		-Continuous improvement of respectful maternity care
		-Training for all staff
		-Pain management education
		-Recommendations for building a rapport with women and reducing abuse
	Respect for team competence and role	-Using each other’s competence
	Respect for team competence and role	-Supporting new colleagues
	Improving midwife work condition	-Team working
		-Logistics for privacy in the ward
		-Logistics for alternative birthing position
		-Improved wages and conditions of service

Results/findings

Search outcomes

The database search identified a total of 1883 articles. Of these, 1883 titles were screened, 1773 duplicates and irrelevant were removed, and 110 articles remained for abstract reading and screening. Of the 110 articles for abstract screening, 27 were excluded for the following reasons: Systematic review = 4 home birth = 3, stillbirth = 1, congress = 4, strategy = `5, meta-synthesis = 3, scoping review = 2, book = 1, and other language = 4. Thus, 84 articles remained for full-text reading. However, 62 were excluded since the articles were quantitative methodology (n = 6), article was not focus on respectful maternity care (n = 30), duplicated (n = 3), sample was not midwife (n = 2), midwifery student (n = 2), irrelevant (n = 10), midwife focus on-barrier (n = 4), ethical issues on abortion (n = 1), and impact COVID-19 (n = 2). Articles were not written in the English language were excluded. Finally, 22 articles were included in the meta-synthesis process. Figure 1 shows the PRISMA flow diagram of the outcome of the search strategy.

Characteristics of the studies

After removing duplicates, titles and abstracts of the remaining citations were thoroughly assessed for the potential inclusion based on our criteria (Figure 1). A total of 22 studies were found as eligible in terms of the inclusion criteria: 19 papers were qualitative (qualitative study, qualitative exploratory inquiry, and qualitative exploratory descriptive study), 1 was phenomenology approach and 2 were mixed-method design studies. Table 3 shows the summary results of the review of these studies. Finally, our analysis was reported under the following themes and subthemes (Table 2).

Table 3.

Summary of the results of included studies.

Author (ref)	year	Country of publication	Study design	Sample size (N)	Data collection method	Type of analysis done	Main themes	Quality score
Hirut Dinku Jiru et al.¹²	2021	Ethiopia	Qualitative exploratory descriptive study	10 midwives	Semi-structured interviews	Descriptive statistics for the socio-demographic characteristics and thematic data analysis	Five main categories emerged from the in-depth interviews with midwives• Trusting relationships with women• Compassionate and respect based behaviors• Good communication skills and holistic care• Intentional disrespect toward women• Barriers to compassionate and respectful maternity care due to structural factors	High
Waleola B et al.¹⁷	2022	Nigeria	Qualitative study	20 midwives	Semi-structured individual Interviews	Clarke and Braun’s thematic method	Mean themeHumanized birth careWomen-oriented care	High
D-zomeku et al.¹¹	2020	Ghana	Qualitative study	15 midwives	Semi-structured individual face-to face in-depth interviews	Open code was used to manage and analyses the data	Three themes emerged• Awareness of respectful maternity care• Motivations for respectful maternity care• Midwives’ recommendation for optimal respectful maternity care	High
Ndwiga et al.¹⁸	2017	Kenya	Mixed methods	13 midwives	Qualitative in-depth interviews	Bivariate analyses	Themes emerged:Understanding and operationalization of client’s rightsProviders’ work-related environmentEmotional healthPerceptions on supervision, job fairness, and management	Moderate
Moridi et al.¹⁹	2020	Iran	Qualitative study	24 midwives	Semi-structured interviews	Graneheim and Lundman’s 2004 method	Three themes were extracted from the content analysis• Showing empathy• Women-centered care• Protecting rights	High
Shimoda et al.²⁰	2018	Tanzania	Qualitative study	14 midwives	Semi-structured interviews	Content analysis was used to analyze the data	For respectful care, five categories were identified: 1) positive interactions between midwives and women, 2) respect for women’s privacy, 3) provision of safe and timely midwifery care for delivery, 4) active engagement in women’s labor process, and 5) encouragement of the mother-baby relationship For disrespectful care, five categories were recognized: 1) physical abuse, 2) psychological abuse, 3) non-confidential care, 4) non-consented care, and 5) abandonment of care. Two additional categories emerged from the unprioritized and disorganized nursing and midwifery management: 1) lack of accountability and 2) unethical clinical practices	High
Bukola Ige et al.¹³	2021	Nigeria	Qualitative exploratory inquiry	20 midwives	Semi-structured individual interviews	Clarke and Braun’s thematic method	Themes:Physical abusePhysical abuse not acceptable Physical abuse was acceptable if life (s) was at riskPrivacyConfidentiality use of dignified tone/language/threat/failure to provide services obtaining consent for procedureDiscriminationAllowing birth companion during labor and delivery, availability of showers, water, and a clean environmentDetention of patientMobility availability of meals and drinksPositioning during first stage and second stage availability of commodities and supplies for labor and deliveryPain relief in labor and delivery	High
Ogbuabor et al.²¹	2021	Nigeria	A mixed-methods design	56 midwives	Focus group discussions	Qualitative data were analyzed thematically	Themes:Dignity and respectCommunication and autonomySupportive care	High
Skoogh et al.²²	2019	Sweden	Phenomenology	19 healthcare professionals (midwives, nursing assistants, and physicians)	Face-to-face interviews	Analyzed according to Dahlgren and Fallsberg's seven steps	Safeguarding the woman,safeguarding the birth process, respecting the individual and the team, and managing workforce and learning.	Moderate
Sahai et al.²³	2017	Ethiopia	A qualitative study	13 midwives	In-depth interviews	Deductive and inductive thematic content analysis	Category of disrespect and abuseNon-consented careAbandonment or denial of careNon-dignified care (including verbal abuse)Physical abuseNon-confidential careDiscrimination based on specific attributesDetention in facilities	High
Millicent Dzomeku et al.²⁴	2020	Ghana	Exploratory descriptive qualitative research	96 midwives	Individual in-depth interview	Pen code 4.03 was used to manage and analyses the data	The themes revealed that socioeconomic inequalities, provider perception and victim-blaming, and health system-related factors facilitate D&AC	High
Silveira Leal et al.²⁵	2019	Brazil	An exploratory, descriptive, and qualitative research	5 midwives	Semi-structured interview	Analysis followed Bardin’s content structure	Theme:Working conditions and humanization practices at work and birth: a fragile relationship	High
Mirzaee Rabor et al.²⁶	2016	Iran	Qualitative study	11 midwives	In-depth semi structured interview	Conventional content analysis with MAXQDA	Theme referred to “Empowerment of women in vaginal childbirth”	Moderate
Mamuda Aminu et al.²⁷	2019	Malawi	A qualitative study	9 healthcare providers	Focus group discussions (FGDs) were conducted separately	Analyzed using the thematic framework approach	Important themes that emerged included: The importance of a valued patient-provider relationship as determined by a good attitude and method of communication, the need for more education of women regarding the stages of pregnancy and labor, what happens at each stage and which complications could occur, the importance of a woman’s involvement in decision-making, and the need to maintain confidentiality	High
Millicent Dzomeku et al.²⁸	2021	Ghana	Descriptive qualitative research	14 midwives	In-depth interviews	Analyzed using NVivo 12 codes	Three themes: Experiences of practicing RMC in daily maternity care, health facility barriers to practicing RMC, and recommendations for improving RMC practices	High
Malesela et al.²⁹	2019	South Africa	Phenomenology approach	18 midwives	Semi-structured interviews	A qualitative data analysis method was used to analyses data	Three main themes emerged, namely, interpersonal skills, improved staff development, and adequate resources	High
Bohren et al.⁸	2017	Nigeria	A qualitative study	27 midwives	Semi-structured discussion guides	Thematic analysis was used to synthesize findings	Themes emerged:Context of mistreatment in abusePhysical abuseStigma and discriminationNeglect and abandonmentViolations of privacyImpact of mistreatment on care-seekingSolutions to improve the treatment of women during childbirth at the end	High
Uwamahoro et al.³⁰	2019	Rwanda	Qualitative study	28 midwives	Individual in-depth interviews	Thematic content analysis	Theme emerged:Midwives’ awareness on respectful maternity careKnowledge on the seven rights of respectful maternity careKnowledge on different kinds of mistreatment experienced by women during childbirth periodAttitudes of midwives toward RMC during childbirthChallenges in providing respectful maternity care	High
Cheryl et al.³¹	2013	Ghana	Qualitative study	13 midwives	Individual in-depth interviews	NVivo 9.0 for analysis	Theme: Physical abuse, verbal abuse, neglect, and discrimination maltreatment	High
Meghan et al.³²	2016	Nigeria	Qualitative methods	27 midwives	Individual in-depth interviews	Thematic analysis was used to synthesize findings,	Theme: slapping, physical restraint to a delivery bed, Shouting, intimidation, and threats of physical abuse	Moderate
Warren et al.³³	2015	Mali	Qualitative method	67 midwives	Semi-structured interviews.	For the qualitative data, they used qualitative description. Sadowski describes basic or fundamental qualitative analysis as a strategy to summarize qualitative data	Yelling, insulting, and displaying a hostile or aggressive attitude. However, auxiliary midwives also stressed the importance of making women feel welcome and comfortable, sweet-talking to them throughout labor, and providing quality care.	High
Mamadou Diouldé Balde et al.³⁴	2017	Guinea	Qualitative methods	13 midwives	In-depth interviews (IDIs) and focus group discussions	Thematic analysis	Theme: Pinching or slapping a woman during labor, yelling or shouting at a woman during labor and childbirth, refusing to help woman during labor, and forcing a woman to deliver on the floor of the hospital	Moderate

Findings

The synthesis of 22 primary studies generated six main themes, and these are discussed as follows under the themes: Midwives’ conceptualizations of respectful maternity care (RMC), Midwives commitment to woman’s rights, The value and impact of respectful maternity care to midwives, Midwife’s perception of disrespectful care, Challenges in providing respectful maternity care during labor, and Midwives’ recommendations for optimal respectful maternity practice.

Theme 1: Midwives’ conceptualizations of respectful maternity care (RMC)

This theme is nested under describes midwives’ understandings of RMC.^11,19

Midwives have different attitude on their conceptualizations on RMC during childbirth.

The many agreed that women need to be respected.³⁰ The midwives spoke about how treating women as unique people^11,19,28,35 with empathy and dedication,^20,22,35 always putting the patient first,^11,17 and integrating clients and family members in their care all contributed to stronger relationships between providers and clients.^17,19,20,28 By taking into account women's interests and expectations, it supports care that is oriented on women.^11,17,19,28 Ten studies contributed data to this theme, with findings extracted under the categories: Treat mother with respect, respect for women decision and autonomy, providing equal care, preserving privacy and confidentiality, women-centered care, and the value and impact of RMC on midwives.

Subtheme: Treat mother with respect

There was evidence that midwives thought a positive first impression was crucial for giving RMC. The midwives gave some indication that they were aware of amicable relationships. According to midwives, developing a cordial rapport with women may be accomplished by speaking to them with respect and using gentle words.^13,17,19,36

According to midwives, it is considered appropriate to greet patients and their family members politely and to refer to them by name and title rather than by bed number or illness.^11,17 A example from midwives stated: “When a mother arrives, we should kindly welcome her and call her name in a respectful manner. In this way, she would feel comfortable.”¹⁹

The majority of midwives reported that they introduced themselves appropriately to women,¹¹ some midwives indicated that “as for introducing ourselves, we do not always do that.” It was explained that “we are conversant with them. We live with them. We are familiar with them. We know ourselves. They will even call you on the phone before coming to the hospital.”³⁵

Subtheme: Respect for mother's autonomy and decision-making

Regarding the participation of women and their relatives in care-related decisions, midwives were divided.^11,17,19,35 Some midwives mentioned that “we give individualized care and respect their autonomy as long as mother and baby are safe.”³⁵ Involving clients and family members entails discussing care options with them so they can make an informed decision to accept or deny care. Midwives emphasized that patients are entitled to care.¹⁷ For example: When a patient feels that she is allowed to decide what happens, how it happens, when and why, she believes you are providing respectful maternity care.¹⁷

Others, however, argued that the woman shouldn't always have a say in medical choices and that there are times when it is unsafe to comply with her wishes, such as when performing an emergency caesarean section or starting labor or when midwives disregard the demands of women. If a woman declares, “I never give birth without a hot drip,” yet there is no medical justification for speeding up the delivery.^22,35 In a study, the majority of patients were not permitted to deliver in their preferred position or with friends or family present.²³

Subtheme: Preserving privacy and confidentiality

Midwives also said that mothers should not be examined in attendance of unnecessary individuals.^12,17,19,27

This is an example: “It is important when we perform any intervention for women, nobody should be a there.”

According to midwives, screens and curtains were used to provide visual seclusion, and patient data were held in absolute confidence.^17,27,35 According to midwives, patient information and health condition are also covered by the concept of privacy, which goes beyond the body itself.

For example, the midwife said: Even for HIV positive women, the midwife will not reveal her HIV status to her husband if the lady states, “I do not want my husband to know about this.”^11,17,27,35 The midwives sometimes inquired about the women's private or intimate matters in front of other people.²⁰

Subtheme: Providing equal care

The majority of midwives said that they treated all women equally, regardless of their individual characteristics (their educational background, age, social status, religion, and race)^11,17,35 and treat them equal.³³ Caretakers should respect everyone and avoid from discriminating against women based on their culture, habits, or religion, according to some midwives. This mentality makes it easier and better to provide respectful care. In this regard, for example, the midwife said: “When they come here, the rights of women from every culture and traditions should be protected and we must pay attention to them.”¹⁹

Subtheme: Women-centered care

This subtheme focuses on women-centered care which was identified in three descriptive categories: women individual care, obtaining consent to procedure, and respect for choices and preferences.

Sub-subtheme: Women's individual care

The majority of the midwives highlighted respect mother's specific care when characterizing this topic, which entails taking into account the birthing woman's own experiences, emotions, and reaction to labor and care.¹¹ On the other side, individualized care is prepared to fit a woman's unique needs as opposed to regular treatment provided to all women in labor.^19,28,35

This is evident in the following statements: Well, there are a lot of clients who come here. And each one has peculiar characteristics. Let’s use labor as an example. Someone will go into labor quietly. If you don’t get close to her, by the time you realize, she will deliver the baby without you. But someone else will shout and wail from 2 cm till the end. So, each person is different... you should be able to care for each childbearing woman devoid of discrimination. You first determine the peculiarities, and then give her appropriate care that will help make the childbearing woman better.¹¹

sub-subthemes: Obtaining consent to the procedure

Respectful maternity care is a service that midwives expressly provide by describing procedures to patients and obtaining their agreement and participation in order to let the patient make an informed choice about whether or not to have the treatment performed.¹³

The majority of midwives used questioning and language-based descriptions of care procedures to get permission from women. When a lady signs permission during admission, midwives explained.^{11,13,17,18,27} This is evident in the following statements: if we want to do anything for them, we obtain a consent, informed consent, we inform about the procedure and respectfully ask for their consent whether they want the procedure to be performed on them especially vaginal examinations, and we explain the procedure.¹⁷

Sub-subtheme: Respect for choices and preferences

Allowing a companion of her choosing to remain with a lady is one of the finest supports we can provide her. The majority of the time, women were not given an option in any of the research that were included.^19,28,37 Respectful maternity care was seen by midwives as accepting women's ideas, whether they were correct or not. This was reflected in the statement: “You should respect them in all aspects, which include respecting their opinion, give them the options available for them choose, and don’t enforce your opinion on them.”¹⁷ Only one research claimed that birth partners may be used if the patient was unwilling to comply; the birth companion had to convince the patient to cooperate.¹³ Other studies, according to midwives, restricted women's delivery positions to the conventional lithotomy position in accordance with hospital practice.^13,24,28

Subtheme: Evidence-based care

For patient safety, it was claimed that observing, reporting, and monitoring the mother throughout delivery were essential.^13,22,33 According to midwives, prompt attendance at the patient's bedside is essential to providing respectful care and maintains the woman's health.^13,19,20 Patients were thought to be safe by receiving supportive treatment and being attentive to the lady.³⁸ The danger of unneeded interventions and possible patient damage is decreased, according to midwives, when a woman discloses information about her care.²²

The midwives held the view that any injury to women and newborns should be avoided, as well as inappropriate procedures without a medical reason.^19,22,24 For example, the midwives stated: “First of all, we all want to give a scientific care and perform it accurately. We don’t need to do some interventions such as unnecessary vaginal examinations, forced early admission, and electronic fetal heart monitoring continuously during labor and birth.”¹⁹ A research, however, reported using non-evidence-based treatments to avert unfavorable outcomes,²⁸ while other studies reported using subpar care and ignoring patient-centered care.^20,28

Theme 2: Midwives commitment to woman’s rights

This theme reflects on the midwife’s ability to implement of respectful maternity care with findings reflected under the subtheme: Midwives awareness on RMC, midwives’ knowledge of RMC, attitudes of midwives toward RMC, and midwives’ skills.

Subtheme: Midwives' awareness of respectful maternity care

There was evidence that midwives were aware of the rights of women. Midwives reported that they have had a course training RMC during their curriculum. Midwives asserted some awareness of respectful maternity care and woman-centered care.^11,30

For example: “Yeah, we have learned those rights in ethical course, and we have internal regulations. We all know that clients need to be respected, informed about the procedure and confidentiality.”³⁰ But in a study, midwives reported that receive limited training on women’s rights.²³

For example: “I didn’t take any [special patient’s rights training]. But I remember some part of it: if a mother comes to the facility, the midwife has the obligation to protect her from any infection. She has the right to get the service she came for. She has the right that her secrets be kept confidential. She has the right for her questions have to be answered.”²³

Subtheme: Midwives’ knowledge of respectful maternity care

Midwives’ knowledge was indicated to have the power to build communication, provide information, and help women make decisions. The majority of participants understood well seven rights and midwives were knowledgeable on the RMC.^11,12,30

For example: “I understand women’s rights as the right to be provided with explanations to her health problem, being treated as a human being, playing a role in her healthcare, and privacy so that she can feel satisfied with the service provided.”³⁰

subtheme: The attitudes of midwives toward respectful maternity care

Different midwives have varied opinions on how they felt about RMC during birthing. Most midwives say they have a favorable attitude regarding RMC. When a woman is giving birth, midwives help her by respecting her choices and preferences²³ and by not berating her when she sobs during a contraction instead of trying to teach her coping mechanisms,³⁰ being among women,³⁰ attending to the woman's emotions,²² and listening to her.^19,33 They often get close and learn how to communicate with one another, which improves the relationship between patients and medical professionals.^20,22,27,35

For example: “Yes of course.” We provide respectful maternity care. Let us take for example: I cannot examine a mother in presence of others due to the respect on her privacy. Indeed, I need to provide all needed services in general. Sometimes there are mothers who cry when they are feeling contractions; in this case, you do not blame them but we educate them on how she should cope with contractions.” While giving maternal care, other volunteers, on the other hand, had a negative attitude. Shouting at moms,^8,30 insults,³⁷ being hostile,³³ and stigmatizing attitudes²³ are the most often reported. For example: “Sometimes you can shout on the mother, or you do not provide the essential healthcare needed or performing suturing without anesthesia and pain relief drugs and she may be in uncomfortable place, I think this also is not good for her.”

Subtheme: Midwives’ skills

This theme reflects on the midwife’s ability to good communication, holistic treatment, empathy with mothers, and supportive care that demonstrated professionalism.

Sub-subtheme: Empathy with mothers

By introducing themselves, demonstrating empathy and trust, and taking into account the women's feelings, the midwives demonstrated effective communication techniques.^12,17,19,20 In order to build trust and confidence between women and midwives, midwives believed that they needed to be in contact with the women they were caring for and make an effort to connect with them in the labor ward.¹² Additionally, they would foster an environment of friendliness and trust to protect RMC by developing a positive connection.¹⁹

For example: The midwife must be with the women during labor and childbirth. A positive relationship with laboring women can certainly be constructed by staying in touch with her.

Sub-subtheme: Supportive care

To assist women in coping with and managing their pain during childbirth, midwives are knowledgeable about the stages of labor and pain management. The majority of midwives said that they pay attention to women, have empathy for them, provide psychological support, and often manage women's discomfort.¹⁷ Midwives often used techniques including constant reassurance, counseling, encouraging women to do deep breathing exercises, walking, and massage to reduce discomfort during birth.³⁵

This is evident in the following statements: the midwives are there to support that childbearing women at that moment, so, assist in sacral massage, and give her encouraging words in order that the childbearing women will not feel that she is in that alone. . .there are a lot of childbearing women in there, so we are in as their support to go through their labor and the pain. . .So, we are the caregivers and we are also the supporters. . .we are giving them the support during the labor.¹¹

Midwives get information on the status of labor, and this information may be used to assist women in making decisions regarding their care and interventions.^19,27 Even after she had finished her shift, midwives remained with the woman and continued to provide her both emotional and physical care.¹²

For example: “We respect the women when give information about progress of labor. We tell them what is going on at every stage and what they can do to help themselves, this would reduce their stress. We introduce caregivers and make them familiar with rooms and equipment as well.”¹⁹ However, it seemed that midwives lacked the expertise necessary to help women in delivery postures that did not use lithotomies. Women could only give birth in the traditional lithotomy position.^13,24,28,39

Sub-subtheme: Communication skill

Communication abilities and holistic care are reported as of primary importance and these include: being a good listener and having the ability to articulate ideas are among the communication skills listed as being of the greatest value²² by respondents. Participants emphasized the value of interacting with women using words that are meaningful, compassionate, and inspiring as well as non-verbal cues including touch, tone of voice, and facial expression.^17,20,33 In order to maintain the assistance, they also recorded occasions when the midwife's presence provided the lady with emotional and physical supports at the conclusion of her shift.¹² For example: “I greet her warmly, introduce myself and take the time to explain what will happen next, and allow her to ask questions and address her needs.”¹²

However, midwives mentioned a few problems that impact their interaction with women during birth, such as poor interpersonal skills, and a language barrier.²⁹ In a study reported, a serious challenge in midwives’ relationship with women and their families was linked to Insults and by upper-class women who demanded a better service.³⁸

Theme 3: The impact of respectful maternity care on midwives

In this theme, the midwives mentioned that they all were proud about the benefits for their own practice when they invested time in establishing good communication with mothers and these are discussed as follows under the subthemes:

Subtheme: Pride in their work

There is a modest amount of research showing that giving high-quality treatment also has real impacts on medical professionals. Building relationships with women has long been recognized as being beneficial to midwives' satisfaction,¹¹ as well as to their professional worth and levels of self-confidence and self-esteem and increased dedication.^18,29,38

This is evident in the following statements: The most important thing is to deliver a healthy baby, but that ultimately depends on the kind of care rendered to the mother…., if you educate her to do everything correctly, the pushing becomes exceptional when the time is due; the mother has the energy to push and the baby is strong.¹¹

Subtheme: Social benefit

The midwives demonstrated that the benefits they have earned due to providing RMC.

Midwives mentioned being respected by mother’s family and community,^11,38

For example, the midwife stated:

“They [the childbearing women] really remember whatever you do to them. Sometimes you meet them in town, and they call you and you feel happy. They sometimes say, “This is your grandchild,” and you are like, wow! “I haven’t even given birth yet, but I have a grandchild.”¹¹

Sub theme: Religious beliefs

Midwives mentioned that religious beliefs them to serve as midwives, and that motivates them to provide good RMC.¹¹ For example: They had the following to say: I believe God has given me this opportunity [serving as a midwife] so I won’t let Him regret giving me the blessing.¹¹

Theme 4: Midwife’s perception of disrespectful care

This theme refers to disrespectful actions were described as having harmful impacts on psychological of women and these are discussed as follows under the subthemes:

Subtheme: Disconnect between awareness and practice of respectful maternity care

Although the midwives treated the ladies with respect, they were aware of abuse that took place during labor. Midwives reported that insulting and shouting at childbearing women are forms of Disrespected and abused care.²⁴

For example: “Midwives are purposefully shouting at women to save their lives and the lives of their unborn infants… but they are unaware of it; the woman has been harassed; yelling at women is not personal; disrespect toward women on purpose.”¹²

Subtheme: Midwife perception of caregiver abuse

Majority of midwives reported at the verbal abuse and physical abuse directed at women during childbirth, an act repeated as being rude.^8,13,23 In other research studies, 48% of midwives described verbal and/or physical abuse⁸ and said that midwives do not use the correct language for the clients. When confronted by the provider, the customers could also feel embarrassed.^{11,12,20,23,37} This rude behavior amounted to physical^{8,20,32,34,37} and mental or psychological abuse.^8,20,32,37

The following are the expressed views of the midwives:

Midwives belied that physical or verbal abuse were acceptable if life (s) was at risk.¹³

The majority of midwives, however, saw it as “verbal encouragement because even though what you say to the women may sound harsh, it will spur them to take action that leads to a positive outcome.”³³

Sub-subtheme: Internalized and normalized disrespected and abused care

Midwives reported that shouting, threatening, and restraining childbearing women during labor can prevent infant and maternal death.²⁴ This belief suggests that disrespect and abuse care is internalized and normalized by these midwives.³⁵ Additionally, several midwives thought it was difficult to cope with women who were pregnant. According to the midwives' opinions, it is clear that these attitudes about childbearing women have caused them to treat women with disdain and maltreatment.^8,32 The following are the expressed views of the midwives. “And with the verbal, that is, where midwives falter a lot; when we talk, we don’t think of the impact it has on the patient, but sometimes we talk anyhow to the patient….”

Subtheme: The violation of women-centered care

The midwives discussed what they saw to be a breach of women-centered care. They said that when midwives behave in ways toward women who don't conform to their expectations for considered “acceptable” conduct during labor, and caregivers are violating the principles of patient-centered care.^24,33

Sub-sub theme: Discriminatory care

In contrast to their peers in the special ward, non-compliant, mentally ill, HIV/AIDS+, and young patients experienced frequent disrespect and abuse, according to midwives, who emphasized that impoverished, disadvantaged populations were at greater risk for disrespect and abuse care.^8,24 The following are the expressed views of the midwives “It is because the mother is infected with HIV that is the reason why my colleagues didn’t want to treat her…”²⁴

Sub-sub theme: Neglect and abandonment

The midwife disregarded the lady and left her to labor alone. Even she was clueless about how to handle the infant and the placenta and didn't seem to have had enough instruction or experience.¹² Most of the midwives were eventually caught ignoring, disregarding, or leaving women in labor. As a result, many births took place without the benefit of midwives' care.^12,13,20

Sub-subtheme: Non-consented care

When the midwives needed to carry out a medical procedure or physical examination, they often did so without warning or the women's permission.^20,23,24

The midwives' stated opinions are as follows: “I have seen verbal abuse and stitching episiotomies without anesthetic, although in the case of the latter, medical professionals assert that utilizing anesthetic may sometimes cause a delay in wound healing. Additionally, I've seen that clients aren't informed before treatments like episiotomies are done.”²³

Women were reduced to spectator status during childbirth as a result of the convergence of physical and informational control. Some midwives' statements made it obvious that this was supported by a conviction that the midwife knew best and an expectation that women should follow instructions.^21,35 For example, the midwives stated: “in this part of the world, it is mostly healthcare providers that make delivery decisions. Even with some enlightened women, after educating them, they will still come back to you with ‘nurse what do you want me to do?’”³⁵

Sub-subtheme: Refusing to help women during labor

This theme refers to midwives refusing to help a mother during labor, for example, “when women ask for support or has a question.”^32,34

Sub-subtheme: Uncooperative woman

Many midwives felt compelled to keep women under control in order to prevent negative results for which they would be held accountable. The midwives reported that childbearing women in labor seldom heeded their advice, and this lack of respect sometimes forced them to perform disrespect and abuse care.^8,24,28 Discipline was used to impose the exertion of authority and control over women in addition to the frequent use of screaming or yelling.^20,24,33 According to midwives, slapping pregnant women's thighs during the second stage of labor encourages them to push and deliver infants safely.^11,34

Midwives demonstrated four factors that precipitate verbal abuse. First, some women come to the hospital without any birthing materials.^28,35 Secondly, when women refuse to disclose their HIV status, midwives normally frown at that.^8,35 Thirdly, some mothers lack good personal hygiene: “some women come to the hospital without taking their bath. It’s annoying.”³⁵ Finally, non-adherence to midwife’s instructions by women or their relatives.^20,24,37 Midwives said that they scold mothers to elicit their co-operation for a positive birth outcome: “if the woman gets up or closes her legs when they head of the baby is already out, you must use a harsh tone to bring the woman down.”³⁵

Theme 5: Challenges in providing respectful maternity care during childbirth

More than nine studies contributed data to this theme, with findings reflected under the categories: Health system barriers, low salary, right to information, timely healthcare, hospital managerial rules, midwives’ position in the health system, and need in midwifery training on the RMC.

Subtheme: Health system barriers

The midwives mentioned that shortage of staff, shortage of resources, lack of motivation, and lack of providing timely care as the identified barriers in the health system for provision of RMC by midwives.

Sub-subtheme: Shortage of resources

Resources include supplies and commodities, bed spaces, and hospital equipment. The midwives remarked that the absence of cardiotocography (CTG) has made monitoring difficult for them.^34,40 Due to the delayed identification of fetal distress, the risk of newborn deaths has increased.³⁰

The midwives also cited difficulties they had in providing seclusion for birthing mothers in the open labor unit due to a lack of logistical support. They noted that since there are only two screens in the facility, it is challenging to offer intrapartum care for more than two women at once.^20,28,30 The following are some of the responses “The privacy screens … for now, we have two of them outside for patients so sometimes, if you have maybe three labor cases, it means two will be provided with privacy and the others not.”²⁸

In a research, midwives said that the transfer procedure might be difficult due to a lack of space and certain standards in the maternity ward, which results in the denial of transferred cases despite the fact that there are no open spaces.³⁰

The ability of providers to promote RMC was significantly shaped by their working settings.¹⁸ The policies and constructed environment at the hospital do not promote the investigation of various delivery positions, according to midwives who participated in another research. However, they said that their institution lacked the necessary tools for implementing the alternate delivery positions, allowing them to put their newly learned abilities to use.^28,29

This is evident in the following statements: “The alternative birthing positions. It seems because we haven’t gotten the necessary equipment, all our patients have to take the lithotomy position.”¹⁸

Sub-subtheme: Shortage of midwives

Seven studies expressly mentioned that human resources were the main issue of midwives.^{12,18,22,27,29} Insufficient staffing was cited by midwives as one of the biggest obstacles to providing RMC at work. Some service providers also cited boredom or tension as a cause of irritation that resulted in abuse or neglect.^12,18,22,27 This is evident in the following statements: “Most challenging is when you come to work and you feel there are inadequate staff…like two staff against 45 patients and you have emergency coming in..”^29,37

Sub-subtheme: Lack of motivation

Sometimes midwives lessen their commitment considering the low payment they get compared to their “effort” and words of encouragement, and other welfare packages.^{8,12,23,29,38} This is evident in the following statements: “Our monthly payment and workload are not proportional; often this will annoy you because life is very costly and you can represent your anger on your customers.”¹²

Sub-subtheme: Lack of providing timely care

The majority of midwives expressed their readiness to provide RMC at work, but the majority also acknowledged that doing so presented problems, most of which were related to their heavy workload and its effect on communication between midwives and mothers.^21,30 Another research found that because to workload and time constraints, midwives seldom explain processes to get permission.^13,30

The midwives warned that providing disrespectful care might result from being overworked and under-resourced.^8,27 Most participants claim that they don't get timely treatment because of their busy schedules.³⁰ This is evident in the following statements that the fragile relationship of working conditions with regard to the implementation of humanization practices for women in labor: it happened on my shifts that I had to get a patient out of bed, put her sitting on a chair because there was a patient in the corridor sitting on active labor, and I had to get the patient out of bed. […] this is totally inhuman.²⁵

Subtheme: Hospital managerial rules

In a research, midwives said that the registration and check-up procedures required before getting medical treatment may delay the involvement of certain instances that need emergency care.³⁰ “Disorganized midwifery administration” was one of the elements leading to the disregard for women. Their order to respond to a birth seemed arbitrary since they were not consistently allocated to a group of women. One of the midwives would be instructed to perform the delivery while a lady was giving birth in front of them.²⁰ One of the finest supports we can provide a woman, according to midwives, is to let a friend of her choosing remain with her. According to hospital management standards, women were often denied their option in several research studies.^19,28,37 Other studies, according to midwives, restricted women's delivery positions to the conventional lithotomy position in accordance with hospital practice.^13,24,28 For example: “One of the best supports that we can provide for woman is to allow companion of her choice to stay with her. If the companion has taken part in the birth-preparation classes, she/he can help the mother to have a better experience.”

Subtheme: Midwives’ position in the health system

The opinions of midwives on their own position within the hierarchy of the healthcare system were nested under the subject “institution centered.” Obstetrician-led care is provided by midwives who work under the supervision of the attending obstetrician. As a consequence, midwives are unable to decide on their own to let women to participate in the selection of their medical treatment. This care paradigm does not prioritize women's needs and is mostly focused on unnecessary medical procedures.

The midwives held that any injury to women or newborns should be avoided, and that any superfluous procedures without a medical reason should be stopped.^19,23 One midwifery lecturer stated: “First of all, we all want to give a scientific care and perform it accurately. We don’t need to do some interventions such as unnecessary vaginal examinations, forced early admission and electronic fetal heart monitoring continuously during labor and birth.”

A midwife in charge of the labor unit said that “it is difficult to provide women-centered and respectful care when the births are managed by obstetricians. She emphasized that the midwife-led care is an appropriate model of care for improving the RMC.”¹⁹

Subtheme: Midwives being disrespected by a coworker

Midwives reported that the disrespect they receive from coworker will affect their communication with the women. During rounds in the mornings, they were often blamed for errors.³⁸

Subtheme: Need to midwifery training on the respectful maternity care

In some study, midwifery reported that their education did not include RMC, and most of us did not receive it as part of their in-service training.^11,12,19

Theme 6: Midwives’ recommendations for optimal respectful maternity practice

Subtheme: Continuous training for improving of respectful maternity care

Midwives suggested that, to ensure optimal RMC, they should provide continuous training on RMC and improving their work condition, logistics for alternative birthing positions, and privacy in the ward and team working.”^24,29

Sub-subtheme: Respectful maternity care training for all staff

The midwives suggested that the RMC modules be taught to all staff at the institution. They also suggested that the instruction be directed at midwifery students at nursing training institutions.^28,41

This is evident in the following statements: “The management should organize workshops for the whole department so that all midwives would be able to get the privilege to go to the workshop because it is very helpful.”²⁴

Sub-subtheme: Enable midwives to implement the alternative birthing positions

Midwives suggested that in order to introduce alternate delivery positions, all midwives should have the necessary training.^28,29

Sub-subtheme: Pain management education

The stages of labor and pain management should be clearly explained to childbearing women, according to midwives. They think that this instruction would make it easier for pregnant women to handle and control their labor pains.^11,23 This is evident in the following statements: As they are in pain, mostly the clients do not listen to the midwives when they advise them. She [the client] may insult us when we advise her to be positioned on her side. They don’t even listen at all.²³

Sub-subtheme: Continuous improvement of respectful maternity care

Participants' comments made it clear that staff members needed to be lifelong learners and engage in ongoing professional development. The participants noted that skilled and knowledgeable midwives enhance the ambiance of the birth unit.²⁹

This illustration demonstrates the discrepancy between RMC midwives' knowledge and performance. “In the second stage of labor, the midwives said that pounding the thighs of the pregnant women helps them push and deliver infants safely.”^8,11

Sub-subtheme: Recommendations for building a rapport with women and reducing abuse

The majority of the midwives' suggestions in a research were centered on community education and counseling skills to help them establish rapport with patients during first meetings and better explain procedures to patients beforehand.²³ This instruction need to include coping strategies for dealing with difficult situations, ways to motivate healthcare providers, and methods for boosting endurance, tolerance, and patience.^8,41

For example: “Sometimes the midwife just does what he has to do without creating a good relationship with the client, even without giving the advice she [the client] needs. As for the laboring mother, when they are in labor pain, their conduct also changes, and sometimes they may even beat the provider, this also breaks the good relationship. The approach and initial rapport-building phase by the provider are critical.”

Subtheme: Improving midwife work condition

In this theme, the midwives for better implementation of RMC recommended: Improved wages and conditions of service and logistic for privacy in the ward and alternative birthing positions.

Sub-subtheme: Improved wages and conditions of service

Midwives suggested improving salaries and other welfare package of providers and increasing staffing to alleviate stress and pressure on them.^8,12,41

Sub-subtheme: Logistics for privacy in the ward

Midwives mentioned that the hospital management should provide enough curtains.^24,41

This is evident in the following statements: “They should provide us with the logistics, and if curtains and other things can be provided...so, now that we have a new facility and there are cubicles, they can provide curtains … for us to ensure a little privacy …”

Sub-subtheme: Logistics for alternative birthing positions

The midwives asked that the labor ward should be equipped with the necessary supportive equipment.^24,41

This is evident in the following statements: “The recommendations I can make, or we need, are the positions kits required to enable us to implement the other positions we know. Because, just as we’ve been talking about, suppose we get these kits, we may not even revert to the lithotomy position.”

Sub-subtheme: Team working

A greater comprehension of each other's competency and knowledge of what to do in various scenarios was cited by midwives as a result of team training. When presented with challenging birthing circumstances, this openness may help people make better judgments that you trust each other enough to express your opinions, talk about a situation, show that the solutions aren't always obvious, and want to talk about your options.^22,29

Subtheme: Respect for team competence and role

The informants described the importance of knowing each other's professional collaborative, especially effective teamworking in emergencies when many actions are performed simultaneously, for example: “…If healthcare professionals are not familiar with each other's competence, uncertainty and lack of trust can develop...”^22,29

Sub-subtheme: Supporting new colleagues

It is important for experienced midwives to adjust their support to new midwives and to make them feel secure.

For example, “… it would be good to have two midwives present at every childbirth […] so you could watch and learn.”²²

Sub-subtheme: Using each other’s competence

The midwives described the importance of knowing each other's role, especially in emergency situations.

For example, “… we are familiar with each other's competence and can complement and help each other.”²²

Discussion

This study identified key areas of midwife’s perception of disrespectful and respectful maternity care. We found that numerous midwives aspire to RMC but face significant challenges. A number of challenges in providing RMC and recommendations for optimal RMC practice were reported. Our finding explicitly addressed the power differential with other study.⁴² The meta-synthesis process resulted in six major themes: Midwives’ conceptualizations of RMC, Midwives commitment to woman’s rights, The value and impact of RMC to midwives, Midwife’s perception of disrespectful care, Challenges in providing respectful maternity care during labor, and Midwives’ recommendations for optimal RMC practice. The results under the heading “Midwives commitment to woman’s rights” showed that the midwives showed some understanding of maternal care with respect. There may be a gap between understanding and RMC practice when others encourage rude and abusive behaviors such striking, pinching, and implicitly blaming birthing women for abuse. This subject emphasizes the need for midwives to strengthen their clinical and social RMC abilities. Similarly, Dhakal et al. came to the conclusion that respectful maternity care education interventions are necessary in high-income nations as well as middle-income and low-income countries.⁴³

The usefulness and influence of RMC to midwives were also discovered in this meta-synthesis. It was evident that being able to deliver RMC brought a great deal of personal gratification and a feeling of professionalism to many midwives. They spoke of concrete effects on working procedures as a result of RMC's facilitation of trust, collaboration, and communication, which they thought made their jobs simpler.¹¹ A tiny amount of research suggests that giving midwives high-quality care has real impacts on them.^11,18,29 Similar effects of developing relationships with women have long been recognized as critical to midwife satisfaction in Western contexts.⁴⁴ Brazilian healthcare professionals who underwent training to humanize childbirth were said to have better collaboration, stronger dedication, and higher self-esteem.⁴⁵ A humanized delivery program was reportedly introduced in Benin, and midwives reported increased self-worth, self-assurance, and professional value.⁴⁶ More recently, Ratcliffe et al. showed that participation in a participatory intervention in Tanzania to foster a culture of RMC led to gains in providers' work satisfaction, attitudes, and pride.⁴⁷

High caseloads, a lack of personnel, low pay, overworked medical professionals, and stress from their jobs, together with inadequate infrastructure for service delivery, are seen by midwives as having a detrimental impact on their attitudes toward their work.^8,12,30 This is due to the significant resource and human resources for health (HRH) limits caused by austerity policies and economic restraints, which have had a long-lasting, detrimental effect on the budgetary space available for the health system. Studies show that after receiving RMC training, clinicians in maternity facilities exhibit some changes in conduct, attitudes, and convictions, but problems still exist.^28,48 A provider's composite score reflects their grasp of client rights, commitment to providing client-centered care, and attitude toward clients who are HIV positive.²⁸

The other section focuses on how midwives perceive a lack of institutional support, which reflects sentiments of being abandoned by national and local management as well as their midwifery representatives in a hierarchical structure that devalues them.¹⁹ A systematic review of motivation in low-income contexts found consistent evidence of the importance of institutional support on staff motivation.⁴⁹ Perceptions of justice and institutional support have been positively correlated with job satisfaction and intention to stay in post.⁵⁰

Other challenges who midwives encounter in this setting include providing women-centered and respectful care while obstetricians are in charge of the deliveries. As with “non-women-centered care” approach, which is mostly focused on unnecessary medical procedures.^19,23 The advantages of the team midwifery style of care for women's satisfaction throughout pregnancy, delivery, and postpartum have recently been shown by Cochrane studies. Additionally, their studies have shown that midwifery care decreases the frequency of needless medical interventions and increases women's pleasure with birthing.⁵¹

One of the most obvious problems was the prevalent rhetoric about “the uncooperative woman,” which gave midwives authority and control over women and their bodies by punishing disobedience.^11,34 This is consistent with research on midwives' attitudes of (dis)respectful care, where women were seen as purposefully defiant and actively disobeying the midwives' authority, therefore justifying the control and discipline that was applied to them. The deep-seated worry of midwives that they would be held accountable if anything went wrong.⁴

The midwives believed there was little attention paid to, or room was made for, the deficiencies in the health systems that made it difficult for them to provide high-quality treatment. This must be seen in the context of midwives holding responsibility without supervision, backup, or assistance from line managers.⁵² The rhetoric around the “uncooperative” mothers seems to be an effort to portray the woman as willfully undermining the midwife's best efforts and so place responsibility for unfavorable results on the woman.⁵³

Thus, the woman was held accountable for much of the disrespectful treatment she received. Midwives justified their actions by demonstrating that women frequently expressed gratitude and remorse for their conduct.^13,32 This finding is supported by previous research which concluded that a strong and pervasive explanation for the data was that D&A supported midwives' belief that women did not know what to do, particularly during the pushing phase. In their evaluations of maternal effort, timing, and denial of choice of delivery position, there was evidence of disregarding embodied knowledge and assuming authoritative knowledge.^52,54

In fact, their endorsement of disrespectful and abusive behaviors including striking, pinching, and implying that maltreatment of women who are pregnant is the fault of the women demonstrates that midwives' knowledge of RMC is not related to the practice of RMC.

Recommendation for optimal respectful maternity care

Engage the mother

Women not understanding what to do often cause midwives' irritation, demonstrating that the present systems are not sufficiently preparing women.

During antenatal care sessions, childbearing women should be well informed about the stages of labor and pain management in order to guarantee optimum RMC. When admitted to the institution, this instruction will enable childbearing women to cooperate with caregivers and control their discomfort throughout labor.

Focus on training for RMC

We advocated for improving pre-registration instruction on the psychological components of RMC. The social elements of birth ought to be addressed more forcefully in the curriculum, in my opinion. Many midwives showed a lack of understanding of the psychological and physical advantages of empathy, information, being with others, and managing pain. Some people were reluctant to use non-supine birthing methods since they had not been trained in them. The absence of evidence-based practice, such as not accommodating different birth positions, connects with this.

Teamwork

Promote and support cooperation, moving away from particular duties, as a component of professionalism, and a lived aspect of the care model, so the team collaborates with individual women and is rewarded for successful outcomes. Rewarding the group rather than the individual lowers the staff's self-esteem and enables peers to put pressure on underachievers to improve. Community scorecards may be useful in this situation.

Career support for midwives

A strong subject in the professionalization talk is harnessing the motivation for midwifery by recruiting people who actively wanted to be midwives, supporting them to perform at the top of their skill level, and ensuring there is a dedicated career ladder for midwives. It would have a positive impact on the job satisfaction of midwifery.

Conclusion

Numerous midwives struggle to achieve RMC despite having several aspirations. Poor working conditions, a lack of employees, and a lack of support at the facility level hinder professionalism and good practice, allowing bad conduct and attitudes to pass for the norm. Midwives feel undervalued and demotivated because of the low prestige and professional invisibility of midwifery under the supervisor obstetrician paradigm, as well as the absence of a shared vision for the profession's future.

To guarantee midwives are motivated and have chances for professional growth and evidence-based development, an enabling atmosphere is necessary for optimum RMC. RMC has to ensure that there is an appropriate supply of the materials and resources that midwives need to carry out their tasks.

Footnotes

Acknowledgments

The authors wish to express their gratitude to the reviewer comments. Also, we are grateful of the Faculty of Health Science librarian at the University of Ahvaz Jundishapoor medical science provided support with the database search.

Author contributions

SH designed the study. Analyzed the data: SH and SM. Wrote the first draft of the manuscript: SH and SM. Contributed to the writing of the manuscript: SH and SM. Conducted the title and abstract screening: SH, SM, and MI. Conducted the full-text screening and data extraction: SH, SM, and MI. Conducted the quality assessments: SH, SM, and MI. Assessed the confidence of the review findings: SM, MI, and AR. Supervision: MI and AR. Agree with the manuscript’s results and conclusions: SH, SM, MI., and AR. A librarian at the University of Ahvaz Jundishapoor medical science provided support with the database search (MZ).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Correction (September 2024):

This article has been updated with minor spelling corrections(Jondishapour to Jundishapur) since its original publication.

ORCID iDs

Simin Haghdoost

Mina Iravani

Simin Montazeri

Data Availability Statement

All relevant data are given within the manuscript.

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