Patient and provider perspectives on pain and other dimensions of anesthesia experience for cesarean delivery: A qualitative study.

Background: There is a lack of evidence on the importance of pain or other aspects of clinical care in the overall patient experience and patient-centered outcomes in cesarean delivery. The purpose of this study was to discover patient priorities in cesarean delivery anesthesia experience, to compare patient and provider perspectives, and to explore attitudes on shared decision-making around anesthesia choices for cesarean delivery. Methods: Patients with recent cesarean deliveries and clinical care providers were approached using a purposeful sampling strategy for this prospective observational qualitative study. Patients were included if they were in the hospital within 72 hours of a cesarean delivery (scheduled or unscheduled), spoke English fluently, and had term gestation. Providers were included if they currently provide regular clinical care to patients having cesarean deliveries and have at least 3 years of practice experience. Semi-structured interviews were conducted using an interview guide. Interview transcripts were independently coded by three coders and qualitatively analyzed for major themes until thematic saturation was achieved. Results: A total of 42 participants (20 patients and 22 providers) completed interviews. Five major themes emerged reflecting patient attitudes and beliefs toward cesarean delivery experience: 1) effective communication, education, and respect; 2) emotional support by care team; 3) intraoperative pain or discomfort; 4) varying acceptability around pain therapies; 5) stigma surrounding cesarean delivery. Five major themes emerged reflecting provider attitudes and beliefs toward cesarean delivery priorities: 1) complexity of pain responses; 2) multiple pain control strategies; 3) effective communication during emergency cesarean delivery; 4) patient psychological well-being during cesarean delivery; 5) barriers to observing the patients' birth plans. Conclusions: Patients and providers alike prioritize pain management, psychological well-being, and effective communication during cesarean delivery experiences. Patients emphasize relationships and trust in their cesarean experience, while clinicians emphasize clinical complexities and physical treatments. Our results guide future research in patient perspectives in cesarean deliveries.

'I am happy to be listened to': co-creation of a simple tool to measure women's experiences of respectful maternity care in urban Tanzania.

BACKGROUND: Rights-based Respectful Maternity Care (RMC) is crucial for quality of care and improved birth outcomes, yet RMC measurements are rarely included in facility improvement initiatives. We aimed to (i) co-create a routine RMC measurement tool (RMC-T) for congested maternity units in Dar es Salaam, Tanzania, and (ii) assess the RMC-T's acceptability among women and healthcare stakeholders. METHOD: We employed a participatory approach utilizing multiple mixed methods. This included a scoping review, stakeholder engagement involving postnatal women, healthcare providers, health leadership, and global researchers through interviews, focus groups, and two surveys involving 201 and 838 postnatal women. Cronbach's alpha and factor analysis were conducted for validation using Stata 15. Theories of social practice and Thematic Framework of Acceptability guided the assessment of stakeholder priorities and tool acceptability. RESULTS: The multi-phased iterative co-creation process produced the 25-question RMC-T that measures satisfaction, communication, mistreatment (including physical, verbal, and sexual abuse; neglect; discrimination; lack of privacy; unconsented care; post-birth clean-up; informal payments; and denial of care), supportive care (such as food intake and mobility), birth companionship, post-procedure pain relief, bed-sharing, and newborn respect. The pragmatic validation process prioritized stakeholder feedback over strict statistics, lowering Cronbach's alpha from 0.70 in version 1 to 0.57 for the RMC-T. Women valued the opportunity to share their experiences. CONCLUSIONS: The RMC-T is contextualized, validated, and acceptable for measuring women's experiences of RMC. Routine use in facility-based quality improvement initiatives, along with targeted actions to address gaps, will advance rights-based RMC. Further validation and community-based studies are needed.

• Main findings: This study describes the participatory approach involving postnatal women, healthcare providers, health leadership, and global researchers to co-create and validate a tool for measuring women's experiences of respectful maternity care in Dar es Salaam's urban health facilities.• Added knowledge: The iterative process produced a concise, 25-item Respectful Maternity Care Measurement tool that is user-friendly, administered in 15­20 minutes and addresses all mistreatment domains. The tool reflects women's priorities and is well accepted by postnatal women and health leaders.• Global health impact for policy and action: Regular use of the tool can enhance awareness of childbirth rights and drive actions to improve and normalize respectful maternity care in low-resource urban settings.

A Community-Informed Maternal and Infant Health Needs Assessment in Alabama.

BACKGROUND: Maternal mortality is a global clinical and public health crisis. Researchers and leading organizations have highlighted the need for local partnerships to implement evidence-based strategies to mitigate poor outcomes. Alabama has the third highest maternal mortality rate in the nation. Research on the complexity of maternity mortality is strengthening, but poor outcomes in Alabama persist and there is limited data highlighting the perspectives of those on the frontlines of providing and receiving care. PURPOSE: We conducted a qualitative, statewide, community-informed, maternal and infant health research assessment with physicians, providers, professionals, and birthing persons to identify challenges and solutions to addressing the states' poor perinatal health outcomes.   METHODS: Data were collected using a four-phase, research design that included semi-structured interviews, focus groups, one state-wide data sharing event, and five regional data sharing events. Data were collected between January 2020 and October 2021. The data were analyzed using consensus coding and thematic analysis. MAIN FINDINGS: Fifty-nine (N = 59) individuals participated. Three themes emerged: 1) "They were making me feel so overlooked.": A disconnect between perinatal healthcare services and patient needs; 2) "That shouldn't be something you have to ask for": Limitations to providing respectful perinatal healthcare; and 3) "If they work together, they can have all the tools they need.": Building a case for collaborative care. CONCLUSIONS: Participants advocated for a collaborative perinatal healthcare model that focuses on the provision of respectful, quality perinatal healthcare. Our approach can be applied across contexts and used to support the effective implementation contextually relevant maternity care practices.

"Letting themselves go during care" - exploring patient autonomy during co-designed intrapartum care in a Beninese maternity ward.

BACKGROUND: Patient autonomy is central to the provision of respectful maternity care. Enabling women to make decisions free of discrimination and coercion, and respecting their privacy and confidentiality can contribute to positive childbirth experiences. This study aimed to deepen the understanding of how patient autonomy is reflected through social practices during intrapartum care in Benin. METHODS: Semi-structured interviews with women and midwives, a focus-group discussion with women's birth companions, and non-participant observations in the delivery room were conducted within the frame of the ALERT research project. This study analysed data through a reflexive thematic analysis approach, in line with Braun and Clarke. RESULTS: We identified two themes and five sub-themes. Patient autonomy was systemically suppressed over the course of birth as a result of the conditions of care provision, various forms of coercion and women's surrendering of their autonomy. Women used other care practices, such as alternative medicine and spiritual care, to counteract experiences of limited autonomy during intrapartum care. CONCLUSIONS: The results pointed to women's experiences of limited patient autonomy and their use of alternative and spiritual care practices to reclaim their patient autonomy. This study identified spiritual autonomy as an emergent dimension of patient autonomy. Increasing women's autonomy during childbirth may improve their experiences of childbirth, and the provision of quality and respectful maternity care.

Respectful maternity care during childbirth: Experiences and observation among mothers in a tertiary-care institute in Manipur.

Background: Respectful maternity care (RMC) refers to the humane and dignified treatment of a childbearing woman throughout her pregnancy, childbirth and immediate postpartum period. Disrespect and abuse of women during labour, childbirth and immediate postpartum period in health facilities is one of the reasons which deter them from further utilizing maternal healthcare services. The present study was thus undertaken to determine to what extent RMC practices are being followed in a health facility in Manipur. Materials and Methods: A cross-sectional study was conducted from May 2022 to August 2022 in a Health facility among women coming for institutional delivery along with direct observations of the labour room. The study tool comprises a semistructured questionnaire related to respectful maternity care which was adapted from the Person-Centered Maternity Care Scale, a validated instrument. The direct observation method was carried out using a checklist adapted from a standardized tool developed by the United States Agency for International Development (USAID). Descriptive statistics were generated and approval of the study was obtained from the Institutional Ethics Committee. Results: A total of 336 (99.1%) women reported at least one form of disrespect or abuse during childbirth. Maximum abuse (91.4%) was reported in the facility and environment domain. Direct observation done on 22 deliveries in the labour room found that 72.7% of the women experienced at least one form of disrespect and abuse. Two (9.1%) women were observed to face physical force or abusive behaviour. Conclusion: Almost all the women reported at least one form of disrespect or abuse during childbirth. There is a need to improve the health facilities and women need to be treated with dignity and respect as it is being violated according to the findings in many studies as with ours.

Does mistreatment during institutional childbirth increase the likelihood of experiencing postpartum depressive symptoms? A prospective cohort study in Nepal.

BACKGROUND: Postpartum depression is associated with low socioeconomic status, adverse birthing processes, and life stress. Increasing evidence of mistreatment during childbirth, negative birth experiences, and poor quality of maternal care is of global concern. OBJECTIVE: To assess the risk of experiencing depressive symptoms among postpartum women exposed to mistreatment during institutional birthing in Nepal. METHOD: We conducted a prospective cohort study from 29 March to 19 August 2022. Of 1629 women who gave birth in a hospital in Nepal, 1222 were assessed for mistreatment during childbirth and depressive symptoms using the Edinburgh Postnatal Depression Scale. We used binomial generalized linear mixed model to examine the risk ratio of postpartum depressive symptoms in women exposed to mistreatment during childbirth. RESULTS: The prevalence of postpartum depressive symptoms was 4.4%. Women exposed to mistreatment during childbirth were almost fifty percent more likely to have postpartum depressive symptoms (cRR 1.47; 95% CI 1.14, 1.89; p = 0.003) compared with the unexposed group. Furthermore, adolescent mothers exposed to mistreatment during childbirth had a seventy percent increased risk of depressive symptoms (aRR 1.72; 95% CI 1.23, 2.41; p = 0.002). Similarly, women who gave birth to female infants were thirty percent more likely to experience postpartum depressive symptoms (aRR 1.32; 95% CI 1.01-1.74; p = 0.039). CONCLUSION: We observed an association between postpartum depressive symptoms and mistreatment during institutional births in Nepal. The implementation of appropriate respectful maternity care during childbirth and also routine screening for depressive symptoms is critical to improving perinatal mental health and well-being.

Main findings: Despite widespread reports of mistreatment during childbirth in health facilities, little is known about possible association with poor perinatal mental health outcomes.Added knowledge: This prospective cohort study in Nepal found an association between postpartum depressive symptoms and mistreatment during institutional childbirth.Global health impact for policy and action: Postpartum depression is a global health issue, and there is an urgent need for interventions to promote respectful maternity care.

"I have to listen to them or they might harm me" and other narratives of why women endure obstetric violence in Bihar, India.

BACKGROUND: Evidence suggests that obstetric violence has been prevalent globally and is finally getting some attention through research. This human rights violation takes several forms and is best understood through the narratives of embodied experiences of disrespect and abuse from women and other people who give birth, which is of utmost importance to make efforts in implementing respectful maternity care for a positive birthing experience. This study focused on the drivers of obstetric violence during labor and birth in Bihar, India. METHODS: Participatory qualitative visual arts-based method of data collection-body mapping-assisted interviews (adapted as birth mapping)-was conducted to understand women's perception of why they are denied respectful maternity care and what makes them vulnerable to obstetric violence during labor and childbirth. This study is embedded in feminist and critical theories that ensure women's narratives are at the center, which was further ensured by the feminist relational discourse analysis. Eight women participated from urban slums and rural villages in Bihar, for 2-4 interactions each, within a week. The data included transcripts, audio files, body maps, birthing stories, and body key, which were analyzed with the help of NVivo 12. FINDINGS: Women's narratives suggested drivers that determine how they will be treated during labor and birth, or any form of sexual, reproductive, and maternal healthcare seeking presented through the four themes: (1) "I am admitted under your care, so, I will have to do what you say"-Influence of power on care during childbirth; (2) "I was blindfolded … because there were men"-Influence of gender on care during childbirth; (3) "The more money we give the more convenience we get"-Influence of structure on care during childbirth; and (4) "How could I ask him, how it will come out?"-Influence of culture on care during childbirth. How women will be treated in the society and in the obstetric environment is determined by their identity at the intersections of age, class, caste, marital status, religion, education, and many other sociodemographic factors. The issues related to each of these are intertwined and cross-cutting, which made it difficult to draw clear categorizations because the four themes influenced and overlapped with each other. Son preference, for example, is a gender-based issue that is part of certain cultures in a patriarchal structure as a result of power-based imbalance, which makes the women vulnerable to disrespect and abuse when their baby is assigned female at birth. DISCUSSION: Sensitive unique feminist methods are important to explore and understand women's embodied experiences of trauma and are essential to understand their perspectives of what drives obstetric violence during childbirth. Sensitive methods of research are crucial for the health systems to learn from and embed women's wants, to address this structural challenge with urgency, and to ensure a positive experience of care.

Are expectations of labour and birth fulfilled? A qualitative investigation of first-time parents.

AIM: To describe if first-time parents' expectations of labour and birth, explored during the third trimester of pregnancy, were fulfilled or not when investigated 1 year following birth. DESIGN: Qualitative Husserlian phenomenological approach. METHODS: The sample comprises 10 parents (five couples), who participated in an online semi-structured audio-recorded individual interview conducted 1 year after birth, between September 2020 and October 2020. Parents' expectations of labour and birth, described throughout a focus group discussion on pregnancy, were compared with their experience explored 1 year after birth. A thematic analysis was adopted and member checking was used to validate participants' thoughts. RESULTS: Participants gave birth in a II level maternity unit and one-to-one midwifery care was provided. Although during the focus group conducted in pregnancy, women reported being aware of the unpredictable nature of childbirth, they expressed sadness and failure after experiencing some unexpected interventions. The midwife was a reassuring guide, as expected; however, sometimes, the communication was not effective, and women perceived lack of support. Some women partly blame themselves for not being prepared to manage labour pain, which hurt more than expected. Feeling of uncertainty about events were experienced in relation to seeking care at an early stage of labour, which confirmed the fears expressed during pregnancy. During the antenatal focus group discussion, fathers doubted they could be helpful for the labouring women. This negative emotion was confirmed after birth. However, they understood the importance to be present and to support their partner. CONCLUSIONS: One year after birth, participants had consistent memories of their birth experience. Professionals might identify fundamental components of quality maternity care that are meaningful for parents, with the potential to generate a long-term positive health impact on them. Respectful maternity care should be ensured through a family-centred approach, with the aim to promote satisfaction. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The study highlights the importance of taking parents' expectations into account when providing antenatal care to tailor individualized support that addresses their distinct needs and preferences. Healthcare professionals might consider initiating a post-natal discussion with parents to assess whether their needs and perspectives have been addressed. This perspective may present valuable insights to achieve long-term positive outcomes, provide high-quality maternity care, address issues and make improvements. IMPACT: The study showed that 1 year after birth, parents can accurately recall their birth. They might also give significant insights into fundamental components of care that they value as crucial to shape a positive birthing experience. Professionals should use this information to build solutions, promoting long-term well-being for parents. Respectful interactions and trusting relationships emerged as key elements in parents' experience. A midwifery care focused on parents' needs may contribute to the achievement of positive birth memories. REPORTING METHOD: This study used the Standards for Reporting Qualitative Research checklist. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

A case study analysis of a successful birth center in northern Uganda.

BACKGROUND: Mothers and infants continue to die at alarming rates throughout the Global South. Evidence suggests that high-quality midwifery care significantly reduces preventable maternal and neonatal morbidity and mortality. This paper uses a case study approach to describe the social and institutional model at one birth center in Northern Uganda where, in over 20,000 births, there have been no maternal deaths and the neonatal mortality rate is 11/1000-a rate that is lower than many high-resource countries. METHODS: This case study combined institutional ethnographic and narrative methods to explore key maternal and neonatal outcomes. The sample included birthing people who intended to or had given birth at the center, as well as the midwives, staff, stakeholders, and community health workers affiliated with the center. Data were collected through individual and small group interviews, participant observation, field notes, data and document reviews. Iterative and systematic analytical steps were followed, and all data were organized and managed with Atlas.ti software. RESULTS: Findings describe the setting, an overview of the birth center's history, how it is situated within the community, its staffing, administration, clinical outcomes, and model of care. A synthesis of contextual variables and key outcomes as they relate to the components of the evidence-informed Quality Maternal and Newborn Care (QMNC) framework are presented. Three overarching themes were identified: (a) community knowledge and understanding, (b) community integrated care, and (c) quality care that is respectful, accessible, and available. CONCLUSIONS: This birth center is an example of care that embodies the findings and anticipated outcomes described in the QMNC framework. Replication of this model in other childbearing settings may help alleviate unnecessary perinatal morbidity and mortality.

Exposure to disrespectful maternity care and perceptions of respectful maternity care among nursing and midwifery pre-registration students in China: A national cross-sectional study.

AIMS: To 1) determine the prevalence and types of disrespectful maternity care witnessed by students; 2) describe students' perceptions of respectful maternity care and associated factors; and 3) investigate whether witnessing disrespectful care influences their perceptions of respectful maternity care. BACKGROUND: Limited evidence exists about nursing and midwifery students' perceptions of respectful maternity care and prevalence of disrespectful maternity care in China. Understanding students' perceptions can inform pre-registration curricula and clinical practice programs, promoting the implementation of respectful maternity care. DESIGN: An exploratory national online survey was conducted. METHODS: Data were analysed using bivariate analysis and multi-factor analysis of variance. RESULTS: Among 733 students, positive perceptions towards respectful maternity care were common. Approximately one-fifth witnessed disrespect, with physical violence, lack of communication and untimely care most frequently reported. A better understanding of respectful maternity care was associated with female students of Han ethnicity, majoring in midwifery, undertaking a longer internship/practicum and reporting fewer instances of observed disrespect. Although students reported positive perceptions of respectful maternity care, inadequate understanding was evident. Incorporating relevant content about respectful care into the curriculum is suggested. Reducing students' exposure to disrespectful maternity care may ensure that certain forms of disrespect or abuse do not become normalized among students. This requires system-level efforts to create a safe and supportive working environment for maternity health providers. CONCLUSION: To promote respectful maternity care in China, system-level changes are warranted. Respectful maternity care needs to be essential content in pre-registration midwifery and nursing curricula. Encouraging students to identify poor practice and discuss good practice in a safe learning environment is warranted.

Role of Obstetric Violence and Patient Choice: Factors Associated With Episiotomy.

INTRODUCTION: In the United States, 1 in 6 women reports obstetric violence in the form of physical and verbal abuse, coercion, and lack of informed consent. Despite recommendations against routine episiotomy, its use in the United States remains notable and varies considerably. This study aimed to analyze the various forms of obstetric violence associated with undergoing an episiotomy and having a choice in undergoing an episiotomy. METHODS: Data from the cross-sectional Listening to Mothers in California survey were analyzed using weighted sample. Logistic regression models were conducted to compute adjusted odds ratios (aORs) and 95% CIs for undergoing episiotomy and having a choice in it. RESULTS: Overall, 21% of the respondents reported undergoing an episiotomy, and 75% of them reported not having a choice in undergoing this procedure. After adjusting for covariates, feeling pressured to induce labor (aOR, 1.31; 95% CI, 1.28-1.35) and to use an epidural analgesia (aOR, 1.82; 95% CI, 1.77-1.88) increased the odds of undergoing an episiotomy. Having a midwife during childbirth significantly reduced the odds of an episiotomy. Respondents who indicated being handled roughly by health care providers were 95% less likely to have a choice in receiving an episiotomy (aOR, 0.05; 95% CI, 0.04-0.06). DISCUSSION: This is the first study to examine other forms of obstetric violence as correlates of episiotomy and having a choice in it. Standardized institutional measures against obstetric violence, patients' ability to make autonomous decisions through informed consent, and engaging midwives could decrease medically unnecessary labor procedures and associated complications.

When addressing resources is not enough: lessons learned from a respectful maternal and neonatal care provider training intervention evaluation in Kenya and Tanzania.

BACKGROUND: Respectful Maternal and Neonatal Care (RMNC) maintains and respects a pregnant person's dignity, privacy, informed choice, and confidentiality free from harm and mistreatment. It strives for a positive pregnancy and post-pregnancy care experiences for pregnant people and their families, avoiding any form of obstetric violence. Though RMNC is now widely accepted as a priority in obstetric care, there is a gap in resources and support tools for healthcare wproviders to clearly understand the issue and change long-established practices such as non-humanized caesarean sections. MSI Reproductive Choices (MSI) manages 31 maternities across 7 countries with a zero-tolerance approach towards disrespectful maternity care and obstetric violence. MSI developed and implemented a hybrid training package, which includes an online module and 1-day in-person workshop that allows healthcare providers to explore their beliefs and attitudes towards RMNC. It leverages methodologies used in Values-Clarification-Attitudes-Transformation (VCAT) workshops and behaviour change approaches. METHODS: The impact of this training intervention was measured from the healthcare providers' and patients' perspectives. Patient experience of (dis)respectful care was collected from a cross-sectional survey of antenatal and postnatal patients attending MSI maternities in Kenya and Tanzania before and following the RMNC training intervention. Healthcare providers completed pre- and post-workshop surveys at day 1, 90 and 180 to measure any changes in their knowledge, attitudes and perception of intended behaviours regarding RMNC. RESULTS: The results demonstrate that healthcare provider knowledge, attitudes and perceived RMNC practices can be improved with this training interventions. Patients also reported a more positive experience of their maternity care following the training. CONCLUSION: RMNC is a patient-centred care priority in all MSI maternities. The training bridges the gap in resources currently available to support changes in healthcare wproviders' attitudes and behaviours towards provision of RMNC. Ensuring health system infrastructure supports compassionate obstetric care represents only the first step towards ensuring RMNC. The results from the evaluation of this RMNC provider training intervention demonstrates how healthcare provider knowledge and attitudes may represent a bottleneck to ensuring RMNC that can be overcome using VCAT and behaviour change approaches.

An investigation into the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companionship in Tehran: a qualitative inquiry on mitigating mistreatment of women during childbirth.

BACKGROUND: A birth companion is a powerful mechanism for preventing mistreatment during childbirth and is a key component of respectful maternity care (RMC). Despite a growing body of evidence supporting the benefits of birth companions in enhancing the quality of care and birth experience, the successful implementation of this practice continues to be a challenge, particularly in developing countries. Our aim was to investigate the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companions to mitigate the mistreatment of women during childbirth in Tehran. METHODS: This exploratory descriptive qualitative study was conducted between April and August 2023 at Valiasr Hospital in Tehran, Iran. Fifty-two face-to-face in-depth interviews were conducted with a purposive sample of women, birth companions, and maternity healthcare providers. Interviews were audio-recorded, transcribed verbatim, and analyzed using content analysis, with a deductive approach based on the Implementation Outcomes Framework in the MAXQDA 18. RESULTS: Participants found the implemented program to be acceptable and beneficial, however the implementation team noticed that some healthcare providers were initially reluctant to support it and perceived it as an additional burden. However, its adoption has increased over time. Healthcare providers felt that the program was appropriate and feasible, and it improved satisfaction with care and the birth experience. Participants, however, highlighted several issues that need to be addressed. These include the need for training birth companions prior to entering the maternity hospital, informing women about the role of birth companions, assigning a dedicated midwife to provide training, and addressing any physical infrastructure concerns. CONCLUSION: Despite some issues raised by the participants, the acceptability, adoption, appropriateness, feasibility, and fidelity of the implementation strategies for birth companions to mitigate the mistreatment of women during childbirth were well received. Future research should explore the sustainability of this program. The findings of this study can be used to support the implementation of birth companions in countries with comparable circumstances.

The Social Context of Pregnancy, Respectful Maternity Care, Biomarkers of Weathering, and Postpartum Mental Health Inequities: A Scoping Review.

Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.

Respectful maternity care interventions to address women mistreatment in childbirth: What has been done?

INTRODUCTION: Over the last decade, there has been an increasing number of studies regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing severe postpartum depression among the women who experienced them. This constitutes a serious violation of human rights. However, few studies have carried out specifically designed interventions to reduce these practices. The aim of this scoping review is to synthetise available evidence on this subject, and to identify initiatives that have succeeded in reducing the mistreatment, D&A that women suffer during childbirth in health facilities. METHODS: A PubMed search of the published literature was conducted, and all original studies evaluating the efficacy of any type of intervention specifically designed to reduce these negative experiences and promote RMC were selected. RESULTS: Ten articles were included in this review. Eight studies were conducted in Africa, one in Mexico, and the other in the U.S. Five carried out a before-and-after study, three used mixed-methods, one was a comparative study between birth centres, and another was a quasi-experimental study. The most common feature was the inclusion of some sort of RMC training for providers at the intervention centre, which led to the conclusion that this training resulted in an improvement in the care received by the women in childbirth. Other strategies explored by a small number of articles were open maternity days, clinical checklists, wall posters and constant user feedback. DISCUSSION: These results indicate that there are promising interventions to reduce D&A and promote RMC for women during childbirth in health facilities. RMC training for providers stands as the most proven strategy, and the results suggest that it improves the experiences of care received by women in labour. CONCLUSION: The specific types of training and the different initiatives that complement them should be evaluated through further scientific research, and health institutions should implement RMC interventions that apply these strategies to ensure human rights-based maternity care for women giving birth in health facilities around the world.

Refugee women's and providers' perceptions of person-centered maternity care: a qualitative study in two refugee camps in Chad.

BACKGROUND: Globally, mistreatment of women during labor and delivery is a common human rights violation. Person-centered maternity care (PCMC), a critical component of quality of care, is respectful and responsive to an individual's needs and preferences. Factors related to poor PCMC are often exacerbated in humanitarian settings. METHODS: We conducted a qualitative study to understand Sudanese refugee women's experiences, including their perceptions of quality of care, during labor and delivery at the maternities in two refugee camps in eastern Chad, as well as maternity health workers' perceptions of PCMC and how they could be better supported to provide this. In-depth interviews were conducted individually with 22 women who delivered in the camp maternities and five trained midwives working in the two maternities; and in six dyads with a total of 11 Sudanese refugee traditional birth attendants and one assistant midwife. In addition, facility assessments were conducted at each maternity to determine their capacity to provide PCMC. RESULTS: Overall, women reported positive experiences in the camp maternities during labor and delivery. Providers overwhelmingly defined respectful care as patient-centered and respect as being something fundamental to their role as health workers. While very few reported incidents of disrespect between providers and patients in the maternity, resource constraints, including overwork of the providers and overcrowding, resulted in some women feeling neglected. CONCLUSIONS: Despite providers' commitment to offering person-centered care and women's generally positive experiences in this study, one of few that explored PCMC in a refugee camp, conflict and displacement exacerbates the conditions that contribute to mistreatment during labor and delivery. Good PCMC requires organizational emphasis and support, including adequate working conditions and ensuring suitable resources so health workers can effectively perform.

Outcomes of the MAMA Training: A Simulation and Experiential Learning Intervention for Labor and Delivery Providers to Improve Respectful Maternity Care for Women Living with HIV in Tanzania.

Respectful maternity care (RMC) for women living with HIV (WLHIV) improves birth outcomes and may influence women's long-term commitment to HIV care. In this study, we evaluated the MAMA training, a team-based simulation training for labor and delivery (L&D) providers to improve RMC and reduce stigma in caring for WLHIV. The study was conducted in six clinical sites in the Kilimanjaro Region of Tanzania. 60 L&D providers participated in the MAMA training, which included a two-and-a-half-day workshop followed by a half-day on-site refresher. We assessed the impact of the MAMA training using a pre-post quasi-experimental design. To assess provider impacts, participants completed assessments at baseline and post-intervention periods, measuring RMC practices, HIV stigma, and self-efficacy to provide care. To evaluate patient impacts, we enrolled birthing women at the study facilities in the pre- (n = 229) and post- (n = 214) intervention periods and assessed self-reported RMC and perceptions of provider HIV stigma. We also collected facility-level data on the proportion of patients who gave birth by cesarean section, disaggregated by HIV status. The intervention had a positive impact on all provider outcomes; providers reported using more RMC practices, lower levels of HIV stigma, and greater self-efficacy to provide care for WLHIV. We did not observe differences in self-reported patient outcomes. In facility-level data, we observed a trend in reduction in cesarean section rates for WLHIV (33.0% vs. 24.1%, p = 0.14). The findings suggest that the MAMA training may improve providers' attitudes and practices in caring for WLHIV giving birth and should be considered for scale-up.

Respectful Maternity Care in the United States-Characterizing Inequities Experienced by Birthing People.

OBJECTIVE:  The purpose of this study is to understand experiences of respectful maternity care (RMC) from the perspective of birthing people in the United States from 2013 to 2018. METHODS:  We conducted an online cross-sectional survey of United States birthing people ages 18-50 in April 2018 using SurveyMonkey Audience. Quantitative survey data consisted of demographics and responses to RMC indicators. Qualitative data consisted of comments from individuals regarding their birth experiences. RESULTS:  1036 birthing people participated in the survey. Most births (95%) occurred in hospitals. 16.3% of Black or African American participants reported discrimination compared to 5.5% of participants who did not identify as Black or African American (p < 0.001). Participants who speak a language other than English were also more likely to report discrimination. 19.5% of all respondents felt neglected during their birth experience. Most prevalent experiences of disrespect and mistreatment were related to neglect (most commonly in postpartum phase of care), poor interpersonal communication, lack of respect for patient wishes, negative experience with breastfeeding services, peripartum complications, and discrimination. CONCLUSION FOR PRACTICE: Birthing people in the United States experience many forms of mistreatment, particularly those who identify as Black or African American or speak a language other than English. Patients described experiencing neglect most commonly after birth-an opportunity to improve the provision of RMC postpartum. Strategies to improve quality of maternal health care in the United States should include the provision of RMC as part of a larger effort to reduce inequities in maternal health experiences and outcomes.

Experienced disrespect & abuse during childbirth and associated birth characteristics: a cross-sectional survey in the Netherlands.

BACKGROUND: Experiencing upsetting disrespect and abuse (D&A) during labour and birth negatively affects women's birth experiences. Knowing in what circumstances of birth women experience upsetting situations of D&A can create general awareness and help healthcare providers judge the need for extra attention in their care to help reduce these experiences. However, little is known about how different birth characteristics relate to the experience of D&A. Previous studies showed differences in birth experiences and experienced D&A between primiparous and multiparous women. This study explores, stratified for parity, (1) how often D&A are experienced in the Netherlands and are considered upsetting, and (2) which birth characteristics are associated with these upsetting experiences of D&A. METHODS: For this cross-sectional study, an online questionnaire was set up and disseminated among women over 16 years of age who gave birth in the Netherlands between 2015 and 2020. D&A was divided into seven categories: emotional pressure, unfriendly behaviour/verbal abuse, use of force/physical violence, communication issues, lack of support, lack of consent and discrimination. Stratified for parity, univariable and multivariable logistic regression analyses were performed to examine which birth characteristics were associated with the upsetting experiences of different categories of D&A. RESULTS: Of all 11,520 women included in this study, 45.1% of primiparous and 27.0% of multiparous women reported at least one upsetting experience of D&A. Lack of consent was reported most frequently, followed by communication issues. For both primiparous and multiparous women, especially transfer from midwife-led to obstetrician-led care, giving birth in a hospital, assisted vaginal birth, and unplanned cesarean section were important factors that increased the odds of experiencing upsetting situations of D&A. Among primiparous women, the use of medical pain relief was also associated with upsetting experiences of D&A. CONCLUSION: A significant number of women experience upsetting disrespectful and abusive care during birth, particularly when medical interventions are needed after the onset of labour, when care is transferred during birth, and when birth takes place in a hospital. This study emphasizes the need for improving quality of verbal and non-verbal communication, support and adequate decision-making and consent procedures, especially before, during, and after the situations of birth that are associated with D&A.