Data from the five studies that met our inclusion criteria suggested that, with moderate certainty, multi-component RMC policies could increase women’s experiences of good quality care and of respectful care, and reduce experiences of disrespectful or abusive behaviours by staff, and of physical abuse. The evidence on reductions non-dignified care, lack of privacy, verbal abuse, neglect and abandonment, and reduction in episiotomy rates was less certain. There did not appear to be any difference in reports of satisfaction, but this finding was also graded as low certainty.
To date, there appear to be few well-designed, adequately powered controlled studies that have examined the impact of a policy for increasing RMC, either as a single component or package of measures, for women during labour and childbirth. Given that recognition of the nature and prevalence of disrespectful maternity care is relatively recent, this is probably not surprising. Our review is limited by the relatively high risk of bias in the included studies, partly due to the fact that only two were randomized trials, one of which included only two sites, and many of the pre-specified outcomes were not captured in these studies. The data also only represent one region of the world, and the interventions under comparison were highly heterogeneous. It was surprising that no studies were located from regions of the world other than Africa. It is possible that intervention studies in this area are framed differently (as, for example, ‘humanised care’). As noted above, we decided not to include interventions using this terminology, as such studies tend to be focused on reducing specific interventions, or introducing specific models of care, like midwifery led schemes. This omission could be a limitation of the study. However, over 8000 women are included at baseline, and over 7500 at the endpoints, and the findings of the RCT’s are generally reinforced by the observational data. It is uncommon to have so much data from low-resource settings, and the consistent direction of effect across most of the findings suggest that, even if the package of interventions varied, the multi-component design of the studies, targeted across whole health systems, was effective for at least some outcomes.
As in the analysis of survey data reported by Reis et al. , and the model of Jones et al. , the findings suggest that intervention programmes need to pay attention to the interconnectivity between the local community, the culture of the local institution, and the socio-cultural context in which both operate. Staff, as well as service users, can be affected by bullying, and disrespect . This can include horizontal and vertical abuse at work and at home, especially in parallel with gender issues . For staff to be enabled to enact respectful care, they must be in a system in which they, too, are respected, properly and promptly paid, able to do their job well, and where they have access to supplies, clean water, well-maintained equipment, and the potential for updating and development.
Interventions that take account of the needs of the local community, staff, service users, and the service are expensive, difficult to control for, and require authentic commitment and buy in from managerial staff, funders, and local politicians. Often such interventions need time to become fully integrated, but this also means that staff turnover and political changes can remove the people and resources that were originally committed to support the project. Issues of long-term sustainability require prolonged engagement of those intending to implement change. Despite these complications, the studies included in this review do suggest that simple elements in a package of interventions across dynamic systems of maternity care could increase women’s sense of respectful care, and of care quality, and could reduce incidences of disrespect and abuse (especially physical abuse, and high rates of episiotomy) on the basis of objective observation. The lack of effect on satisfaction is probably due to the fact that women’s reports of being satisfied are often highly skewed toward the positive, and depend on their prior expectations .
Qualitative research on respectful care suggests that multiple components are more likely to be effective . Taken as a whole, the interventions used in included studies suggest the need for a shift in values, attitudes and beliefs, and for consistent messages and support across the whole system of care, from the local community, to front line care providers (doctors, midwives, nurses), senior professional and managerial staff, and administrators. Components ranged from caring for the carers (including making sure staff had access to tea and toast in recognition of their inability to leave the ward during a shift due to workload) to the hosting of Respectful Care Workshops, and provision of mentorship, and dispute resolution.
To ensure that RMC policies can be maximally effective in the future, policymakers and maternity service funders should ensure that infrastructure deficiencies leading to disrespectful care (e.g. state or absence of toilets and washing facilities, lack of privacy, overcrowded birth spaces) are addressed. However, such improvements require resources and time, depending on existing infrastructure and resources, and this should not inhibit the promotion and progressive rapid realization of respectful, dignified, woman-centered care for all women in terms of day to day service provision, within the context of a human rights-based approach to reducing maternal mortality and morbidity . As the drivers and types of mistreatment and abuse will vary across settings, these rapid implementation schemes should ensure that local factors are clearly identified through communication with women and women’s groups in their setting/s. RMC interventions should then be tailored to addressing them among all stakeholders to optimize implementation.
Steps that can be taken very quickly at a strategic level include the development and integration of written, up-to-date standards and benchmarks for RMC that clearly define goals, operational plans and monitoring mechanisms policymakers, in collaboration with local services and communities. This work should be initiated and supported by local policy makers and maternity service funders and providers, with local birth activist groups, where they exist. Protocols for RMC and accountability mechanisms for redress in the event of mistreatment or violations, and of informed consent procedures, should be reviewed regularly. Mechanisms should be put in place to ensure that all women, and particularly those from disadvantaged backgrounds, are made aware of their right to respectful, dignified maternity care and of the process they need to use address complaints. This process should be simple, easily located, and culturally normative. It could, for example include service development and audit mechanisms that integrate women’s feedback, and ensures response to complaints.
Although the search strategy for this review did not explicitly include studies where respectful care policies were targeted at specific marginalized groups, RMC policies should recognize local contexts in which subgroups of women may be at particular risk of mistreatment, including those groups with special needs (e.g. poor awareness of their rights, and language difficulties), and ensure that RMC strategies increase levels of respectful care and equity for these women and families. Interest is also growing in the concept of respectful care for the newborn. Along with respectful care for family and friends of those using maternity services, this would be a valuable area for a review in future, as more intervention studies are published in these areas.
Policymakers should be aware that shifts in health system infrastructure, such as reorganization of staffing, or increasing workloads, could disrupt implementation. Any infrastructural changes need close monitoring to ensure and evaluate the feasibility and sustainability of RMC practices.
Current and new initiatives to implement respectful care should be formally evaluated, as a minimum with audit and/or service evaluation techniques, but ideally through controlled designs that can also allow for assessment of effects over time, such as stepped wedge designs, with or without internal action research cycles to take account of local conditions. New studies could also assess the best RMC indicators, in terms of validity and responsiveness in clinical settings, and optional implementation techniques in different kinds of settings. Ultimately, it would be important to assess the impact of increasing RMC on substantive maternal and perinatal birth outcomes, and on longer-term health and wellbeing.