Overview of literature on RMC and applications to Tanzania

Respectful maternity care research in Tanzania continues to increase. This is an overview of the literature summarizing research based on the domains which comprise this quality of care indicator, ranging from exploratory and descriptive to quantitative measurements of birth perinatal outcomes when respectful interventions are made. The domains of respectful care are reflected in the seven Universal Rights of Childbearing Women but go further to implicate facility administrators and policy makers to provide supportive infrastructure to allay disrespect and abuse. The research methodologies continue to be problematic and several ethical cautions restrict how much control is possible. Similarly, the barriers to collecting accurate accounts in qualitative studies of disrespect require astute interviewing and observation techniques. The participatory community-based and the critical sociology and human rights frameworks appear to provide a good basis for both researcher and participants to identify problems and determine possible solutions to the multiple factors that contribute to disrespect and abuse. The work-life conditions of midwives in the Global South are plagued with poor infrastructure and significantly low resources which deters respectful care while decreasing retention of workers. Researchers and policy-makers have addressed disrespectful care by building human resource capacity, by strengthening professional organizations and by educating midwives in low-resource countries. Furthermore, researchers encourage midwives not only to acquire attitudinal change and to adopt respectful maternity care skills, but also to emerge as leaders and change agents. Safe methods for conducting care while addressing low resources, skilled management of conflict and creative innovations to engage the community are all interventions that are being considered for quality improvement research. Tanzania is poised to evaluate the outcomes of education workshops that address all seven domains of respectful care.

In seeking to address maternal mortality, the focus is often on material circumstances (accessibility of care, economic circumstances); the RMC movement centers the birthing women's experience as a key driver of birth outcomes.
The RMC movement seeks to provide common language for categorizing key themes in disrespectful care. There are seven key pillars (or domains) of RMC. Understanding how RMC impacts women's health is essential to educate governments, health workers, and the global health industry about the importance of quality and dignity in the provision of care. Equally important, we must understand the physical, systemic, and emotional spaces that generate disrespectful care. In our personal experience of hosting RMC workshops in Tanzania, we learned firsthand from midwives and nurses about the material and temporal deprivations that shape their context. This literature review provides a broad overview of RMC issues addressed in current research and applications from our experience in Tanzania for practitioners seeking to enable dignified birth and improve birth outcomes in Sub-Saharan Africa and globally.

Background
Respectful maternity care (RMC) is a growing field of research and practice which recognizes that to be effective, health care and assistance during pregnancy and birth must uphold the dignity of the birthing women. How women are treated during pregnancy and labour affects their birth experience and the health of mother and baby. Disrespectful care is a recognized problem worldwide. In low resource settings such as Tanzania, where there is a high maternal mortality of approximately 410-526 per 100,000 pregnancies [1,2], disrespectful care directly impacts women's willingness and ability to access health care and give birth with a skilled health worker. In contrast to projects which focus on material circumstances (accessibility of care, economic circumstances) to address maternal mortality; the RMC movement centers the birthing women's experience as a key driver of birth outcomes.
The RMC movement seeks to provide common language to categorize key themes in disrespectful care. Despite varied opinions about defining 'respectful care' , researchers and practitioners have developed a rigorous and comprehensive rubric focused on seven domains of RMC (See Table 1). These 12 domains reflect seven Universal Rights of Childbearing Women [3].
Understanding how RMC impacts women's health is essential to educate governments, health workers, and the global health industry about the importance of quality and dignity in the provision of care. Equally  Fig. 1). Of these 32 studies, 16 are critically appraised in Table 2. Following are the three themes emerging from the overview: conceptualization and measurement, worklife experience of providers, leadership and change.

Conceptualization of respectful care
Respectful care is emerging as a phenomenon of study since the World Health Organization (WHO) concept ualization was published in 2015 [4]. The White Ribbon Alliance operationalized the conclusions of the WHO into seven domains or standards of disrespectful care in the Universal Rights of Childbearing Women. Across the RMC literature reviewed, the authors found wide acceptance of these categories. While there is some early foundational work on RMC dating back to the early 2000s [5], a majority of the literature reviewed was published after 2010 (See Table 2). We noted a rising spike in publications on this topic, including the WHO conceptualization in 2015 and a Lancet special issue in 2016 [4,6]. As might be expected for a new field of research, much of the literature reflects the preliminary nature of our understanding of RMC. Investigators for case and field studies such as Rosen et al. [7] noted that study designs were pilots and much of the work sought to solidify and validate the domains of RMC. A more recent systematic review by Shakibazadeh et al. confirms previous reviews that capture the global nature of disrespect and abuse; but they go further to identify a total of 12 relational and infrastructural domains, thereby making the facility managers just as culpable in disrespect and abuse. [8] Of note, there are a growing number of observational, descriptive and mixed methods RMC studies specific to Tanzania. [6,[9][10][11][12][13][14][15].
We note that although disrespectful care is observed worldwide, in both the Global North as well as the Global South, disrespectful care by maternal care providers has been studied primarily in low-resource countries such as the Dominican Republic [16], India [5,17], Kenya [18,19], Peru, Burundi [5], Nigeria, and Tanzania [5,7,19,20].
Work documenting disrespectful care contributes to an overall understanding of the subject and suggests methods for quantifying and comprehending the scale of disrespectful care, a first step to combating it.
There is also a growing body of work suggesting and evaluating interventions to improve the quality of care and identifying the conditions that promote respectful care but little in the way of evidence-based clinical guidelines [6]. In contrast, the systematic review by Prost et al. [21] and the study by Bhutta et al. [22] demonstrate that interventions such as deploying community     workers who are skilled in cultural sensitivity and respectful communication strategies might improve maternal satisfaction, service utilization and perinatal outcomes in Pakistan. In a mixed method study that included 52 Tanzanian facilities, Rosen et al. [7] observed that insufficient communication and information sharing by providers, delays in care, abandonment of laboring women, lack of a patient-centered approach by hospital administration and poor infrastructure contributed to disrespectful care (See Table 3). Many authors note that disrespectful care is not well-studied, nor is it well-recorded, and there are methodological challenges to conducting this research [23]. If each of the RMC domains is treated as categorical or dichotomous variable to describe its effect either on facility utilization or on perinatal outcomes, separating the effects of changes to each variable has yet to be designed into logistic regression models. Yet, research utilizing trained community health workers or respectful centering pregnancy models do not control for facility or infrastructure factors. Notwithstanding, there may be ethical dilemmas in purposely eliminating one of the seven factors in favour of examining another. Consequently, though constituting a higher order of evidence [24,25], randomized control trials (RCTs) are problematic. This leaves us with observational, retrospective, case studies, and various qualitative studies to understand why midwives or mothers define some care as dignified or respectful while finding other types of care disrespectful. Women may be reluctant to share experiences of disrespectful care. One author notes that women may not divulge disrespectful care and that the language with which women describe disrespectful care may go unrecognized [26]. For example, in a qualitative study the women often responded positively when first asked about their birth experience generally. However, more careful probing would often reveal disrespectful care (such as "screaming" or "speaking roughly"). This underscores the necessity for a tangible definition of respectful care, such is provided in the seven domains, to allow for uniform documentation [13]. Table 2 summarizes methodologies used to examine all or some of the domains of respectful maternity care in the research reviewed between the years of 2000 and 2016. This foundational research has provided an excellent springboard for action research and quality improvement evaluation following RMC interventions. In the years to come, healthcare providers, policy makers and educators should anticipate curriculum development and post-service training to be informed by the emerging quality improvement research linked to RMC. Within these studies, vulnerable populations have been sampled, such as adolescent mothers [19,27], mothers who are HIV positive [19,20], mothers of lower socioeconomic status, discriminated ethnic groups or castes [17,26], and new immigrant mothers [28], with particular emphasis on their experience of discriminatory beliefs, attitudes and practices [20].
Ratcliff et al. [6] describes the use of an educational program and workshop that involved strengthening many skills in two Tanzanian facilities. The aspects addressed included birth preparedness skills, patient-provider communication and provider-administrator communication skills. They found that patients reported increased feelings of empowerment and confidence during delivery. Providers reported increased job satisfaction and improved quality of care was recorded by external observers. Many researchers emphasize the need for RMC provider training which includes strategies for communication with the hospital administration regarding infrastructure and staffing needs as key elements [29].
A critical analysis of the literature reveals that increased access to high quality care will not necessarily improve outcomes without community engagement. Previously, global development was focused on increasing the numbers of facilities, the equipment, the numbers of providers, and modes of transportation, presumably to improve access to care [13,20,[30][31][32]. However, mothers continued to avoid care due to disrespectful behaviors of the caregivers [18]. Mothers desired and/or were denied adequate informed consent [18,19,28,33,34]. They report that the provider failed to include them in decision-making process surrounding admission and plan of care. They report that they had little understanding of rationale for interventions [19,34,35]. It would be unfair to simply draw conclusions for a causative relationship between disrespectful care and lack of skill amongst providers. However, by hearing the lived work experiences of midwives in the Global South, valuable data has begun to emerge that indicate disrespectful care is a multifactorial phenomenon. Consequently, education of midwives solely, without changing the conditions of midwifery work might prove to be ineffective.

The work-life of the midwife
Researchers are attempting to document the conditions from which disrespectful care emerges. Midwives in the Global South described challenging shortages of equipment and staff [19,36]. They also expressed job dissatisfaction, low morale or motivation, significant desire to quit and inadequate training [34,[36][37][38]. The researchers cited these issues as barriers to caring for women adequately and deterrents to accessing care. Researchers explain that this weak infrastructure discourages respectful care [19,36,38]. (These studies also describe higher incidences of adverse outcomes such as maternal and newborn deaths).
Possibly, midwives who describe a sense of oppression or constraint due to the public and facility policies within which they work, may also be less likely to work efficiently or respectfully [39]. Therefore, rather than a punitive, oppressive approach, educators, researchers and policy-makers have addressed disrespectful care by building human resource capacity, by strengthening professional organizations and by educating midwives in low-resource countries. Furthermore, researchers such as Ratcliff et al. [6] encourage midwives not only to acquire attitudinal change and to adopt respectful maternity care skills, but also to emerge as leaders who challenge policy-makers, institutional administrators and politicians to strengthen the healthcare system and infrastructure that effects respectful maternity care so significantly. Notwithstanding, the process of becoming a change agent is not easy in the Tanzanian context due to the organizational system and culture, where midwives are so immersed in the work of midwifery that they describe being less informed and unable to advocate for themselves regarding their work-life. The next steps in research will require evaluation of the RMC strategies and interventions that have been employed since the 2015 challenges posed by the WHO, preferably including the perspectives of midwives [4].

Leadership and change
It is clear from a few Tanzanian studies that the midwives were attempting to address severe and urgent crises. In fact, Penfold and colleagues [29] noted that distressed staff in Tanzanian facilities coped with the unsatisfactory working conditions by dangerous risk-taking behaviours; including improvisation in the absence of functioning equipment or sufficient supplies, alternative forms of sterilization that are not evidence-based and shorten the life of the equipment, risking their own health and safety by avoiding infection control standards to perform life-saving procedures for patients (e.g., mouth-to-mouth resuscitation for newborns). It is unknown whether their patients or families received these efforts positively, and whether these efforts mitigated some of the perceptions of disrespect that reportedly deter families from using healthcare facilities [14]. Consequently, safe methods of addressing maternal and newborn mortality and morbidity need to be developed. Emerging evidence points to interventions such as education in crisis management, leadership and communication as integral to RMC training.
Clearly action research needs to measure the outcomes of clinical and social innovations employed in the low-middle-income countries (See Table 4). These innovations were in both Tanzania and South Sudan by some of the authors. Qualitative, substantive changes such as creating privacy drapes, using temporary privacy walls with drapes on intravenous poles, obtaining informed consent and refusal. The younger participants with 3-year diplomas and 4-year degrees tended to generate more innovative digital solutions such as an electronic form of the WHO mandated Partograph [40], however these creative ideas require start-up grants and major global health funding to implement.
The participants of the RMC workshops requested ongoing continuing education in RMC. They found the workshops cathartic for those who suffered post-traumatic grief after having engaged in or witnessed disrespect and abuse. They also found the workshops to be synergistic and empowering in terms of findings practical, low-cost, effective solutions to complex social situations, complicated by low resources and high risk clinical decision-making. Recommendations from the participants and consultants were to meet with ministry of health professionals, local midwifery educators and midwife preceptors in social innovation rounds to discuss common goals and troubleshoot for solutions over an interprofessional, informal gathering. In countries rife with high context cultural norms where meetings must be officiated by respected high ranking medical officers or government representatives, these meetings are essential if RMC initiatives are to be endorsed and ratified. Similarly, student midwives learning to apply evidence-informed care need the support of effective midwife allies who will model leadership and courage as they advocate for respectful care of vulnerable clients and culturally safe engagement with the community.

Conclusion
Defining disrespectful care in a tangible way with concrete examples will aid in research and intervention design, as well as the sharing of best practices and interventions. A general terminology and taxonomy of RMC has clearly emerged over the past two decades. This is facilitating knowledge exchanges, and it is also helping to aid researchers and practitioners to gain resources which promote RMC. However, within this broader understanding of how RMC impacts birth outcomes and maternal mortality, we note the importance of centering the birthing person and their inherent dignity in its own right, regardless of the outcomes, lest we exploit respectful care as a fleeting ploy to pacify hospital administrators. We noted that most studies linked disrespectful care to low uptake of skilled birth attendance and negative health outcomes. It is therefore essential to speak of both the impact on birth outcomes (including mortality), as well as the important personal and individual lived experience of the birthing mother. Importantly, it is the experience that the birthing mother brings (biological, ancestral, and lived) that are undermined when personal choice is not respected in the birthing environment (See Table 1, Domain 4). We believe that most authors recognize this implicitly, however, it is worth articulating and repeating. Table 2 describes the various types of research questions that define the RMC problems faced by healthcare providers in low-resource countries. Future research questions need to measure the effectiveness of interventions directed at all seven domains of RMC. Researchers posit that ongoing structural, attitudinal and healthcare system changes will significantly affect facility utilization, perinatal outcomes, healthcare provider retention and the overall quality of maternity care in the Global South [5,18,28]. Tanzania, the recipient of many global development grants, is poised to pilot many of the recommendations emerging from the research (See Table 2).