Table 2 Final set of recommendations for improving of respectful maternity care in the Iran
From: Designing a respectful maternity care guideline: a multiphase study
Statement | Consensus type | Percentage of consensus | Responsible unit |
|---|---|---|---|
Recommendations for pregnancy period | |||
 1. Pregnant mothers should be trained in reasonable expectations | Completely agree/agree | 88.33 | Midwife, Physician |
 2. The patient charter of rights should be made available to pregnant women during visit and treatment stages | Completely agree/agree | 75 | Midwife, Physician |
 3. The pregnant women should participate in delivery preparation classes during her pregnancy and become familiar with her rights with regards to delivery | Completely agree/agree | 100 | Midwife, Physician |
 4. Before the delivery, some sessions should be held for pregnant mothers to establish trust with birth attendants, training maternal rights, and familiarization with different hospital ward | Completely agree/agree | 91.66 | Midwife, Physician |
Recommendations for the labor, delivery and postpartum stages | |||
 5. The number of birth attendants should be reasonable and standard (one-to-one system) in order to prevent the fatigue of healthcare teams and service providers, especially during night shifts | Completely agree/agree | 91.66 | Heads of the center |
 6. It is necessary to consider the privacy of parturient women and attention to cultural as well as religious issues regarding gender differences between the parturient women and healthcare teams at all hospitalization stages | Completely agree/agree | 100 | Midwife, Physician |
 7. Informed consent forms should be taken during examinations and interventions | Completely agree/agree | 75 | Midwife, Physician |
 8. Effective communications should be established between the midwife/physician and parturient women through simple methods in line with women’s cultural backgrounds | Completely agree/agree | 91.66 | Midwife, Physician |
 9. The hospital personnel and birth attendants should avoid reprehension, insult, threats, humiliation, mockery, and any improper or violent behavior | Completely agree/agree | 100 | Midwife, Physician and assistant nurse |
 10. The midwife/physician should have attention, sympathy, heart-warming, promising words (inducing positive spirit) and proper eye contact for the parturient women | Completely agree/agree | 100 | Midwife, Physician |
 11. The midwife/physician should introduce themselves to the parturient women and present their job descriptions | Completely agree/agree | 91.66 | Midwife, Physician and assistant nurse |
 12. All hospital employees should wear uniform costumes so that the parturient women will know their care providers | Completely agree/agree | 100 | Midwife, Physician and assistant nurse |
 13. The midwife/physician should respond to all patients’ questions attentively | Completely agree/agree | 100 | Midwife, Physician and assistant nurse |
 14. The midwife/physician/assistant should treat the parturient women and their companions (especially at initial admission) respectfully | Completely agree/agree | 100 | Midwife, Physician and assistant nurse |
 15. Upon the entrance of the parturient women, the system (a person with midwifery specialty) should be present to welcome and introduce the wards as well as hospital rules | Completely agree/agree | 100 | Midwife, Physician and assistant nurse |
 16. The parturient women’s necessary personal should be easily accessible to them | Completely agree/agree | 91.66 | Assistant nurse |
 17. The midwife/physician should inform the parturient women about their health status, that of the fetus, and that of their family (with no induction of apprehension) | Completely agree/agree | 100 | Midwife, Physician |
 18. The care provider should inform the parturient family about the maternal, fetal, and neonatal status | Completely agree/agree | 91.66 | Midwife, Physician |
 19. The hospital system should avoid providing improper, bad-colored, and old clothing for the parturient women | Completely agree/agree | 91.66 | Assistant nurse |
 20. It is necessary to provide the conditions for the presence of a personal midwife or physician alongside the parturient women | Completely agree/agree | 75 | Head of center |
 21. The necessary conditions should be provided for the presence of doula alongside the parturient women | Completely agree/agree | 100 | Head of center |
 22. The midwife/physician/assistant should avoid disputes, discussion, and whispering about the health status of women in labor (on mother’s bedside) | Completely agree/agree | 100 | Midwife, Physician and assistant nurse |
 23. Constant care should be provided for mothers (in the presence of accompanying physicians or midwives from early stages of pregnancy until delivery and postpartum periods) | Completely agree/agree | 83.33 | Head of center |
 24. Proper nutrition should be provided in labor as well as postpartum for the parturient women | Completely agree/agree | 100 | Assistant nurse |
 25. The physical atmosphere of the admission room, labor, and delivery should be suitable in terms of hygiene, light, temperature, and size | Completely agree/agree | 100 | Head of center |
 26. Proper well-fare equipment and facilities should be provided (e.g., suitable beds, hygienic products, and bath) | Completely agree/agree | 100 | Head of center |
 27. The atmosphere of the delivery center should be relaxing (through the use of vibrant colors, pleasant aroma, suitable decoration, and soothing music) | Completely agree/agree | 91.66 | Head of center |
 28. The emergency ward, labor room, delivery unit, and postpartum unit should be quiet | Completely agree/agree | 83.33 | Head of center |
 29. The parturient women should be involved in the decisions related to their care | Completely agree/agree | 75 | Midwife, Physician |
 30. During the labor and delivery, an informed and trained companion (e.g., a relative or a spouse) should be present alongside the parturient women, or they should have at least a short visit or contact with the parturient women | Completely agree/agree | 100 | Head of center |
 31. Discrimination between mothers should be avoided (experiencing differences in some personal and social characteristics or having an acquaintance in the hospital) | Completely agree/agree | 91.66 | Midwife, Physician and assistant nurse |
 32. Proper persistent and timely care should be provided | Completely agree/agree | 100 | Midwife, Physician and assistant nurse |
 33. Long stays at the hospital should be avoided before initiating the active phase of labor | Completely agree/agree | 100 | Midwife, Physician |
 34. The midwife/physician should explain the course of labor and different sections of delivery to the parturient woman (according to her understanding and language) and convince her completely | Completely agree/agree | 91.66 | Midwife, Physician |
 35. Frequent vaginal examinations should be avoided without acquiring permissions or proper justification of the parturient women | Completely agree/agree | 100 | Midwife, Physician |
 36. During the labor, the parturient women should be able to move freely or change positions | Completely agree/agree | 91.66 | Midwife, Physician |
 37. Pharmacological methods (e.g., venous or epidural opioids) or non-pharmacological methods (e.g., massaging, warm water shower and compress, breathing, and music) should be employed to alleviate pain during labor and delivery | Completely agree/agree | 100 | Midwife, Physician |
 38. The use of early oxytocin administration should be avoided | Completely agree/agree | 100 | Midwife, Physician |
39. The inessential insertion of the bladder catheter should be avoided | Completely agree/agree | 100 | Midwife, Physician |
 40. The constant inessential cardiotocography for fetal health assessment should be avoided | Completely agree/agree | 91.66 | Midwife, Physician |
 41. The delivery status (e.g., sitting, upright, or lying positions) during the delivery (by providing prerequisites including trained attendants and proper environment) should be based on the women’s choice | Completely agree/agree | 75 | Midwife, Physician |
 42. Adequate anesthesia should be used during episiotomy and repair technique | Completely agree/agree | 100 | Midwife, Physician |
 43. Routine episiotomy should be avoided | Completely agree/agree | 100 | Midwife, Physician |
 44. The use of uterine fundal pressure to facilitate delivery in the second stage should be avoided | Completely agree/agree | 91.66 | Midwife, Physician |
 45. During the delivery, the parturient women should be encouraged and supported to exert the force of expulsion | Completely agree/agree | 91.66 | Midwife, Physician |
Recommendation for care of the newborn | |||
 46. The midwife/physician should inform the parturient women about the newborn’s status, the newborn’s gender, and the reason for delay in establishing skin-to-skin contact as well as breast-feeding postpartum | Completely agree/agree | 100 | Midwife, Physician |
Occupational recommendations | |||
 47. It is necessary to employ a healthcare provider team committed to ethical and professional principles and having both physical health and psychological health. The reason and significance of respectful maternity care should be explained at the onset of employment | Completely agree/agree | 91.66 | Head of center |
 48. Welfare facilities as well as financial, spiritual, psychological, legal needs plus occupational security of the midwife/physician should be fulfilled | Completely agree/agree | 100 | Head of center |
 49. It is essential to provide an incentive system which is a kind of serial and timely financial incentive plus promotion and motivation for individuals expressing respectful behavior | Completely agree/agree | 100 | Head of center |
 50. In case of repeating abuse and disrespect, financial punishment and documentation of misconduct should be in order | Completely agree/agree | 83.33 | Head of center |
 51. The system governing the hospital management should be based on dignity with an atmosphere filled with respect with no disputes with the low-rank staff | Completely agree/agree | 100 | Head of center |
 52. The working hours should be adjusted to the difficulty and occupational burnout of staff | Completely agree/agree | 91.66 | Head of center |
 53. In order to enhance the job satisfaction of midwives and gynecologists, discrimination should be avoided between the staff | Completely agree/agree | 91.66 | Head of center |
 54. Midwives and the heads of wards should provide services in different departments alternately in order to prevent depression or occupational burnout | Completely agree/agree | 100 | Head of center |
Supervision recommendations | |||
 55. The patient charter of rights should be publicized in posters so that it would be a constant reminder for studying and observing respectful maternity care | Completely agree/agree | 100 | Head of center |
 56. Pregnant mothers should be surveyed about the behavior and performance of the staff when they are leaving each ward. The results of such surveys should then be enforced | Completely agree/agree | 91.66 | Head of center |
 57. Induction of inhumane and unethical behavior of staff toward each other (e.g., exaggerated pride and sense of superiority over the patient) should be avoided | Completely agree/agree | 75 | Head of center |
 58. An employee with midwifery specialty should be present at different shifts of the delivery (especially during the night shift) frequently and unexpectedly. They should emphasize respect to the parturient women while understanding the midwife and parturient women’s conditions | Completely agree/agree | 100 | Head of center |
 59. There should be a system for accurately dealing with the complaints made by the patients and their companions | Completely agree/agree | 91.66 | Head of center |
 60. Improper and disrespectful behavior of the senior manager of the hospital should be modified and corrected so that it would not be induced to the low-rank staff | Completely agree/agree | 91.66 | Head of center |
 61. There should be regulatory and monitoring mechanisms for not only the physical performance of staff but also their types of behavior | Completely agree/agree | 91.66 | Head of center |
 62. The job descriptions of midwives should be corrected and clarified | Completely agree/agree | 100 | Head of center |
 63. A quality improvement team should be developed to assess and monitor disrespect and abuse in hospital | Completely agree/agree | 100 | Head of center |
 64. Consultation should be provided for mothers who have experienced abuse and disrespect | Completely agree/agree | 91.66 | Head of center |
 65. Executive laws should be formulated to observe respectful maternity care alongside some plans to monitor and review the procedure for enforcing the laws in hospitals constantly | Completely agree/agree | 91.66 | Head of center |
National policy recommendations | |||
 66. Provision of respectful services for mothers should be incorporated in the decisions made by policymakers as one of the main pillars of the healthcare system, which should also be further supervised with regard to its precise implementation | Completely agree/agree | 91.66 | Policy makers |
 67. There should be a national protocol of respectful maternity care with an emphasis on necessity, implementation, precise monitoring, frequent assessment, and removal of barriers to this protocol | Completely agree/agree | 100 | Policy makers |
 68. The grounds for implementing national protocols of respectful maternal care such as human and financial resources as well as hospitalization environment should be provided | Completely agree/agree | 83.33 | Policy makers |
 69. The rights of pregnant women and mothers should be taken into account by policymakers and community | Completely agree/agree | 83.33 | Policy makers |
Recommendations for training students and staff | |||
 70. Proper training in maternal rights, respectful maternity care, communication skills, and effective communication regulations should be incorporated in educational curricula at all medical and allied health fields | Completely agree/agree | 91.66 | Vice Chancellor For Education |
 71. For wrongdoers, frequent and compulsory training courses should be organized | Completely agree/agree | 83.33 | Vice Chancellor For Education |
 72. The behavioral challenges and interactions of gynecological specialists or residents with the midwife and vice versa should be corrected | Completely agree/agree | 100 | Vice Chancellor For Education |
 73. The educational approaches should be changed from merely care-based education with treatment approaches to respect-based care education | Completely agree/agree | 100 | Vice Chancellor For Education |
 74. Frequent educational courses should be held in order to promote communication and behavioral skills in clinical practice | Completely agree/agree | 100 | Vice Chancellor For Education |
 75. Classes in ethics should be held for the staff based on changes in attitudes and values | Completely agree/agree | 100 | Vice Chancellor For Education |
 76. Educational workshops should be provided by presenting posters and visual pamphlets in order to promote communication between the staff and mothers | Completely agree/agree | 91.66 | Vice Chancellor For Education |
Recommendations related to the general public | |||
 77. Respecting the other people’s rights in the society should be promoted widely so that it will become internalized as a cultural value over time | Completely agree/agree | 100 | Policy makers |
 78. The status of childbearing to maintain the family foundation should be internalized and honored in society | Completely agree/agree | 91.66 | Policy makers |
 79. The physical, psychological, mental, emotional, familial, and social advantages of pregnancy should be promoted publicly | Completely agree/agree | 83.33 | Policy makers |
 80. Educational workshops should be organized to familiarize mothers with their rights in society | Completely agree/agree | 91.66 | Policy makers |