Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Introduction

Around 810 women die globally each day from preventable causes related to pregnancy and childbirth, 94% of which occur in low resource settings (World Health Organisation, 2019). Reducing maternal, perinatal and neonatal mortality in developing countries has been a concerted focus of both Millennium Development Goals (MDGs) and Sustainable Development Goals (SDGs) with efforts to address underlying mortality risks by promoting institutional births, increasing skilled professional support and ensuring that every woman has access to basic maternal health care.¹

However, the challenge remains high for sub-Saharan Africa and South Asia in particular to tackle the complex factors contributing to higher mortality.² In resource-limited settings, a range of social, cultural, economic and structural barriers consistently impact on women’s access to care during pregnancy and childbirth,^3,4 thus reductions in related deaths remain a critical challenge for health systems. Furthermore, significant disparities exist within the regions and countries in which the burden of maternal, perinatal and neonatal mortality is highest, concentrated among women who experience disproportionate health inequities and poorer health outcomes associated with structural deficiencies and discrimination.^1,5

The South Asia region includes eight countries – Afghanistan, Bangladesh, Bhutan, India, Nepal, Maldives, Pakistan, and Sri Lanka – where maternal, perinatal and newborn mortality has been an ongoing challenge for the health system. With concerted efforts of all sectors, South Asia has demonstrated a significant reduction in maternal mortality ratio (MMR) from 384 per 100,000 live births in 2000 to 157 in 2017 (World Health Organisation, 2019), underpinned by improved access to skilled providers and quality maternity care.^6,7 These figures contrast to MMRs of 10–18 per 100,000 live births in high-income countries and there is work to be done to continue (and sustain) decreased MMRs.

A critical aspect of continued progress in better maternal outcomes is having access to respectful maternity care (RMC). Based on human rights principles, RMC ensures that every woman receives dignified, equitable care without coercion or discrimination, including the right to her choice of care and preferences during the childbirth to support positive experiences. These rights are violated when a woman experiences disrespect, abuse, refusal or mistreatment by care providers or professionals during pregnancy and childbirth.^8,9 A growing recognition of the extent of mistreatment, abuse, disrespect and neglect of women during childbirth has in turn led to demands for an urgent response to address these concerns.^10,11 Experiences of abuse and disrespect among women giving birth in health institutions create barriers for women seeking health care during pregnancy and birth-related complications, as well as being a serious human rights concern.^12,13

Provision of respectful maternal care requires collaborative efforts across disciplines, systems and stakeholders, including women, families, care providers, health services and health care systems.¹⁴ The increased utilisation of pregnancy-related services by women in South Asia offers an opportunity to demonstrate the impacts of quality care in the further reduction of maternal, perinatal and neonatal mortality. In turn, this supports services to operationalise the concept of respectful maternity care fully in practice, improving positive experiences for women seeking professional services and promoting choice and agency for women. A better understanding of the context of existing practice, barriers and enablers is required to inform RMC practice in South Asia. A scoping review was determined as the appropriate method to map and explore current practice and perspectives in South Asian countries, examining evidence of RMC experiences to women who attend services during pregnancy, childbirth and postnatal period.

Methods

The review used the framework and Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR) guidelines.^15,16

The following questions guided the review process.

1. What is respectful maternity care and how it is defined?
2. What are current practices around respectful maternity care in South Asia?
3. What facilitators and barriers exist in maintaining respectful maternity care in South Asia?
4. Which populations are at a higher risk of not receiving respectful maternity care in South Asia?
5. What actions and policies are required to support improvements in respectful maternity care in South Asia?

Eligibility and Search Strategy

Eligibility criteria comprised peer-reviewed research published in English from 2010 to 2020 that focused on experiences of women, their families, service providers, stakeholders and community (see Table 1).

Table 1 Inclusion and Exclusion Criteria of Studies

An initial limited search of MEDLINE and CINAHL was conducted, followed by a brief analysis of the text words contained in the title and abstract of retrieved papers. A second search using identified keywords and index terms was undertaken across all included databases. Thirdly, the reference list of identified reports and articles from full-text sources included in the screening review was then searched for additional sources. Search terms for CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases related to pregnancy and childbirth; professional and other birth support role; attributes of care; and country location and included maternity OR maternal OR pregnant* OR childbirth OR birth* OR antenatal OR perinatal OR postnatal AND midwife* OR midwives OR obstetric* OR “healthcare provider” OR “health care provider” OR “healthcare professional” OR “health care professional” OR “health volunteer” OR “birth attendant” AND “health services” OR “models of care” OR “health system” OR “health practice” OR community OR healthcare OR “health care” OR “health practice” AND respect* OR dignity OR woman-centred OR “woman centred” OR “client centred” OR “person centred” OR “culturally safe” OR quality OR compassion* OR holistic OR disrespect* OR abuse OR discrimination OR stigma AND “South Asia” OR “South Asian” OR Afghanistan* OR Bangladesh* OR Bhutan* OR India* OR Maldives OR Nepal* OR Pakistan* OR “Sri Lanka” OR Sri Lanka*.

The searches were conducted in November and December 2020, resulting in 1157 articles.

Study Selection

Two reviewers (SK and GV) independently reviewed the titles of identified articles (1157) and those clearly not relevant to the topic were excluded. Abstracts of all articles were reviewed for inclusion using the screening checklist developed with criteria for this review. The full texts of potentially eligible papers (155) were retrieved and reviewed by two reviewers (SK and GV) based on the criteria with a primary focus on respectful maternity care during pregnancy, childbirth and up to six weeks’ postpartum in the South Asia region. During the screening, disagreement between reviewers were resolved by discussion with a third reviewer (MS). See Figure 1.

Figure 1 PRISMA reporting framework for study selection. Notes: Adapted from: Tricco AC, Lillie E, Zarin W et al PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern, Med. 2018;169(7):467–473. doi:10.7326/M18-0850.16 Copyright © 2018, The American College of Physicians. Creative Commons Attribution License (https://creativecommons.org/about/cclicenses/).

Quality Assessment

Two reviewers (SK and GV) conducted assessment independently and discussed together until the consensus was reached in the case of discrepancies. This appraisal process helped to refine and interpret the findings of the review.

Data Extraction

Population and study characteristics, data collection and analysis, themes, author’s interpretations including the data around current practice, barriers, enablers of respectful care, characteristics of abuse and study recommendations were extracted to a standardised table developed for this review (see Table 2).

Table 2 Characteristics of Included Papers

Data Synthesis

A combined inductive and deductive thematic analysis approach was employed, where initial open coding on each relevant text unit elicited key themes emerging from the data. We developed the preliminary coding framework with main domains drawn from the literature and checked against the studies selected for inclusion. All included studies were reviewed until no new themes emerged and the co-researchers agreed on the definition, scope and interpretation of each theme. During the synthesis process, we revised some codes and merged some sub-themes. Based on the initial coding, repeated review of codes and emerging themes, 10 broad themes were developed to provide focused interpretations of the results.

Results

The analysis synthesised findings from 61 studies conducted across seven countries: Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka (Figure 2). No eligible papers from the Maldives were sourced. Most studies explored the experiences of women, with some including perspectives of family members, midwives, obstetricians, midwifery students, hospital officials, community stakeholders and community-based care providers. The research included a mix of quantitative (21), qualitative (29) and mixed methods (11) study designs.

Figure 2 A map of included studies in the review by country.

Table 2 describes the characteristics of included studies. Table 3 summarises the preliminary codes and categories from included studies that addressed the scoping review research questions and guided the development of themes. Ten themes emerged that described issues in the provision of respectful maternity care for women in South Asia. These in turn were grouped, reflecting the focus on two broad overlapping domains that described deficits of care and influencing factors (Compromised quality of care, Context and inequities influencing experiences); and calls for change (Responses and needs, and System level changes – policy, education, funding). Themes and domains were related according to how they were referenced by women, family and community, and workforce (see Figure 3).

Table 3 Aspects of Respectful Maternity Care

Figure 3 A diagram of reported themes from the scoping review.

The 10 themes are described after Table 2.

Women’s Choices and Preferences are Neglected

Women and family members described being neglected by health care professionals when their choices and preferences to manage pregnancy, childbirth and postnatal care.^{18,20,26,29,40} Women found that professionals took control of their birth and employed routine procedures without including them in decision-making processes^65,76 and that this resulted in a lack of trust in the services provided to women.^74,75

Within in the context of family relationships, power dynamics, and the way decisions are made about the services and care within South Asian society, the roles of husband and (in particular) mothers-in-law in making childbirth decisions and expectations regarding practice was critical, with mixed acceptance by women.^{3,39,52,71,74} This signifies the hidden oppression of women within the social construct of power of patriarchal society and how women are often excluded in making decisions about childbirth.⁴

Compromised Quality of Care

Women who utilised the facility-based professional care shared their negative experiences and questioned the quality of care provided to them.^29,39 Limited access to services was described, ranging from medicines, proper equipment, competent, skilled health care and food supplies. These factors all diminished the quality of services in an environment where women felt they had little agency in the choice of services or health care providers.^19,29,33 Women felt their pregnancy and birth was medicalised within the controlled clinical environment of the hospital and reflected on their experience of a lack of basic respect and kindness to women.^20,21

Escalated Abuse, Neglect and Disrespect Among Women Who Experience Health Inequities

Women who already experienced health inequities and compromised health outcomes due to underlying social determinants and discrimination experienced more serious forms of abuse, neglect and disrespect from health professionals.^{35,49,51,56,65,70} This further marginalised and silenced women and their families who felt unable to speak about their negative experiences with health services.^{26,33,34,36,51,56,65,70} Studies questioned the effectiveness of attempts to address inequities in maternity care in socially vulnerable communities.^{26,33–36,49} These women are more likely to experience more frequent and significant maternal, perinatal and neonatal morbidity with an associated increased risk of mortality.

Professional Control of Pregnancy and Childbirth Made Women Feel Fearful

Several studies described women’s experience of professional control of pregnancy and childbirth, which left women with little or no perceived ability to make any decisions about the services.^{20,36,55,65,70,76,77} Women felt they were not involved in decisions about prescribed medicines or procedures and why they were required.^26,53,74 This lack of involvement and communication about procedures resulted in further uncertainties, fear and anxiety for women.^18,36 Women expressed a preference for access to and choices of medical and technological interventions while giving birth.^{33,38,41,59,63,64}

Women Prefer Home Birth to Avoid the Institutional Takeover of the Childbirth

In this context of professional control and institutional takeover of birth, studies described women’s preference to stay away from the hospital environment in order to exercise some freedom of choice.^{18,20,29,36,57,70,76} They were more likely to stay home to give birth and seek assistance from family members and community-based care providers to manage problems they experienced during pregnancy, childbirth and postnatal period.²⁶

Where previous experiences of abuse, disrespect, unnecessary clinical procedures, lack of empathy by midwives and doctors and mistreatment created fear, this aversion increased.^{27,49,56,63,64,67,78} Consequent delays resulted in an increased risk of emergency hospital attendance during pregnancy and childbirth.^{36,49,56,62,67,70,76}

Social, Cultural and Economic Context of Women Played Significant Role in Experiencing Institutional Care

Studies described the social, cultural and economic contexts that impacted on women’s experiences of disrespect, abuse and poor quality of care in the hospital environment. This was heightened for younger women, women from lower socio-economic background, women with disability, women living in rural and remote areas and women from minority religious backgrounds.^{25,44,46,50,69} In South Asian societies women’s needs, choices and preferences were often neglected during pregnancy and childbirth,³¹ leading to psychological distress and anxiety, particularly for those women who lacked support from family and health institutions.⁴⁵ Women and families also spoke about the burden of hidden and unofficial costs required to manage transport, food and other supplies while accessing services in the hospital.¹⁸ One study described an interesting pattern between providers and women regarding their cultural and social background in terms of understanding, empathy, trust and provision of respectful care.²⁰

Involvement of Family, Peers and Community-Based Support Provided Confidence and Comfort to Women

Women described being happy to receive the care, support and respect from family, peers, and community-based care providers,⁴¹ although the family relationships and power dynamics described in the first theme were influencing factors.³ They tended to seek advice and support from families, relatives, friends and neighbours to make decisions about the types of services and the care providers within their socio-economic circumstances.^18,19,72 The collective decisions made about the services for women were based on the intention of gaining positive experiences and minimising the risks of poor birth outcomes. In most cases, women expressed a preference to use traditional birth attendants to support birthing^17,52 and female community health volunteers to seek information before or after childbirth.⁵⁶

Women Want Respect and Dignity from Professionals

Women from diverse settings described hospital environments that created feelings of uncertainties, discrimination, abandonment and neglect by health care providers.^{11,51,52,54,57,59,64,67,70,75} They shared expectations of having health care providers who would listen and understand their concerns, problems and preferences while providing care with a kind attitude.^{18,40,51,52,59,75} Women wanted to be treated with respect and dignity without judgement about their social, cultural and economic backgrounds.^{11,51,52,54,57,59,64,67,70,75}

Women preferred to have female doctors and midwives from their cultural and linguistic background to support positive experiences.^{34,36,45,57,60,63} These findings were congruent with health care providers who agreed about the importance of respect; however, they also highlighted various barriers limiting capacity to do so in their institutional role.^{17,18,20,30,31,41,49,50,54,57,67,76}

Investment in Training and Resources to Promote RMC is Imperative

Health care providers emphasised the need to provide more resources to health care institutions and provide continuous training in respectful maternity care to enable appropriate practice environments.^{20,34,56,64,68} Studies described an urgent need for improved resourcing – including medicine, equipment and other essential items – to provide quality maternity care to all women.^{19,26,28,35,49} Public health care facilities were typically more challenged compared to private based on the available infrastructure, resources, support to staff and knowledge of respectful practice.^28,49 Women and family members further highlighted the issue of cleanliness, better food, medical supplies, promptness of providing care and attitude of the doctors and midwives.^{35,53,59,64,74,75}

Policy and Legislative Changes Required to Enforce Equitable and Respectful Maternity Care Practice

Most studies reinforced the obligation of providing quality maternity care to all women with equity and respect regardless of age, ethnicity, religion, culture, socio-economic background and physical ability.^{20,36,50,60,73,76} Providing women an opportunity to make choices about their childbirth was significant but not understood or practiced by the health care professionals.^19,59 Women and families believed that government has accountability to provide respectful care, but health care providers constantly highlighted the barriers to provide quality of care to women.^{29,33,43,54,55,70}

It was clear that women’s preference was dismissed in the institutional setting and women subsequently became victim of unnecessary clinical interventions.^{17,29,43,54,67} Women from low socio-economic background received little attention from health care providers while receiving care.^{17,21,31,35,50,59} The need for strong policy efforts were recommended as the way to mandate equitable and respectful care in a South Asian context.^{20,36,60,62,78}

Facilitators and Enablers for RMC

Facilitators and enablers to enhance positive experiences to women in South Asia were identified as including support from families, friends, neighbours, relatives, Female Community Health Volunteers (FCHV)s and Traditional Birth Attendants (TBA)s,^{3,36,41,50,52,57,63,67,73,74,79} having access to SBAs in the village,^{26,38,43,50,52,57,63,67,73,79} supporting family members to take women to the birthing centre,^{18,40,51,52,59,74} the provision of a caring, respectful and welcoming institutional environments;^{18,20,21,34,40,51,52,57,59,64} economic support to women to attend care,^27,28,30,78 involvement of female care providers to support birthing,^{34,36,45,57,60,63} access to education and empowerment programs for women,^39,60,70 affordable services to all women;^{18,27,35,51,59} shared understanding and trust between women and health care providers,^49,55,57,68 improved opportunities for women to be involved in discussion and decision-making process about their care,^24,57,63,67 enhancing peer-community support models of care;^{18,41,52,56,70} ongoing training for staff on emerging issues.^{20,34,56,64,68} The roles of midwives and FCHVs were seen as influential in determining women’s experiences and ensuring their access to community-based services.^{21,26,31,34,43,70,74,75}

Barriers to RMC

In summary, barriers to the provision of respectful maternity care included discriminations, disrespectful behaviour, rejection, abuse and exclusion of women in care,^{19,25,30,36,37,44,49,54,56,57,59,60,65} lack of resources, services and access to SBA in rural areas,^{26,42,49,51,52,60,70,73} medical and technological control of birth,^30,32,38,62 poor interpersonal and communication skills of providers,^34,49 consequences of low socio-economic status and lack of decision-making capacity of women,^{19,24,33,51,53,56,58,61,67} different understandings and attitudes of care providers regarding women’s care needs,^20,30,43 the burden of costs and transport access to health care services,^{4,17,18,28,30,35,38,41,48,50,51,60} economic disadvantage, social norms, construct of gender and power in the society,^{3,17,19,21–23,31,39,44,45,50,51,53,63} culturally inappropriate, physically unsafe and unwelcoming hospital environments,^{28,30,40,57,75} poor quality of services in public settings,^{21,27,28,30,44,50,52,55,61,80} lack of knowledge and resources to enable respectful services,^{18,23,46,47,50,51,60–62,64,68} and lack of policy, leadership commitment and accountability of health system.^{46,47,50,58,60–64}

Implications for Policy and Practice

Several studies discussed implications of their findings for evidence-based policies, transformative strategies and respectful professional practice.^20,77 The imperative of appropriate social policies, guidelines, supportive environment and resources to raise awareness about the concept of respectful maternity care was consistently highlighted.^{20,21,24,36,41,43,49,81} Attention to prioritise the improvement of quality of care in health facilities was described.^{17,19–21,27,28,30,39,77,78,81} Addressing systemic barriers requires considering the socio-cultural contexts of women while designing and providing care.^{17–19,33,39,77}

Similarly, investment should be made to increase access to SBA and female care providers^{18,19,21,24,26,35,41,43,49} with parallel efforts to enable women’s access to education, services and economic opportunities.^{17–19,21,26,35,39,79,81}

Several studies argued for improved leadership, commitment and accountability at the government level in order to improve the infrastructure, human resources, social capital and equitable coverage of services.^{17,24,26,35,49,79}

The need for additional and continuing training and access to educational resources for health care providers about respectful maternity care was described as a crucial priority.^{21,34,35,43,81} It was also recommended to involve women, families and communities in health service planning, policy development, service delivery and other decision-making process.^{17,18,21,33,38,40,41,43}

Discussion

The findings of this scoping review draw voices of women, health care professionals, family members and other stakeholders to explore the current practice, facilitators, barriers and policy implications of providing respectful maternity care in South Asian countries. The review found consistent negative experiences of abuse, neglect and disrespect in institutional settings.

Emerging themes captured the experiences of women during pregnancy and childbirth and described the critical complexities of maintaining quality of care within often resource-limited circumstances. Health care providers felt unable to adhere with the norms of providing respectful maternity care to women due to gaps in their own knowledge and skills, resources, institutional supports, policy direction and clinical guidelines.

Vulnerable women and marginalised families experienced higher levels of abuse and discrimination while coming to hospital to receive care. Given the focus of maternity care now is on women centred model where decisions are made valuing the choices and preference that women make,^82–87 this puts women at further risks of marginalisation and raises a serious human rights issue of receiving equitable, quality and respectful care.

Studies in our review consistently described women avoiding institutional pregnancy care due to the fear of being misjudged, mistreated and abused in health care settings. Studies described examples of women lacking agency in decision-making processes about their care, where their choices or preferences were dismissed by the professionals who took control of the birthing process. This suggests a medical domination of care and oppression of women seeking care when fight to survival is critical. The impact of choice and control on women’s childbirth experiences to determine safety has been consistently discussed from the perspective of giving power back to women to decide where and how they would like to give birth.^88–92 However, a lack of trust in health care provision was described where women had a fear of being victimised by their behaviour and actions. While hospitals took actions to ensure the physical safety of women and the newborn, the emotional safety of women needs further attention.^93,94

Social, economic and cultural differences all played influential roles in the experience and provision of care. When women found providers shared similar cultural and religious backgrounds, their experiences of receiving care were typically positive. Similarly, influences of families, friends, neighbours and community-based lay care providers helped women to feel safe, supported and well looked after. The critical role that socio-economic factors play in determining pregnancy and birth outcomes has been the ongoing challenge for disadvantaged settings where maternal and perinatal mortality is still high.^95–99 The findings of this review strongly emphasise the significance of involving women, families, communities and service providers from the similar backgrounds to design and deliver culturally appropriate model of care.

The notion of care that women want and need to experience respectful maternity care in South Asia aligns well with the concept of collaborative care that many countries adopted to provide responsive services to their diverse and culturally rich community settings.^100–105 This review reaffirms that enforcing respectful maternity care practice in South Asia requires systematic actions across all levels of health care system. Health care providers mostly agreed on the principles and necessity of providing respectful maternity care, however it was often described as impractical in the current health system, social practice, institutional resources and policy environment. Other studies confirm that without taking appropriate policy actions, the challenges that each country is facing to ensure the safe pregnancy and birth outcomes will remain longer and women from diverse social and cultural backgrounds will continue face the barriers of accessing respectful and quality maternity care.^106–111

In the context of limited supplies of resources including basic medicine, equipment, staff and lower benefits to the midwives providing care, maintaining welcoming hospital environment and providing quality care to women was considered not possible.

Strengths and Limitations

There is a lack of evidence to understand the current practice of respectful maternity care as a region in South Asia and the significance of enabling the respectful approach to ensure quality of care has not yet got enough attention. This review used a rigorous method for gathering evidence, synthesising data and assessing the validity of findings. The barriers and enablers drawn from experiences of women and others involved in providing care can be instrumental to strengthen relevant policies and respectful maternity care practice across the countries.

These findings cannot be generalised in all contexts of pregnancy, childbirth and postnatal experiences even in South Asia, as the culture, social and structural issues that women experience differ from one place to another. Given that most studies focused on health facility-based experiences from urban and semi-urban settings, there is a lack of insight specific to remote dwelling and other women who are disproportionately affected by social and health inequities. There were no studies found that that met the inclusion criteria from the Maldives, and limited information from Bhutan; thus, insights from these countries are limited and call for resourced research.

Our review focused on respectful maternity care within the context of health services: we acknowledge other factors that profoundly impact on decision-making, childbirth experience and maternal outcomes, particularly familial norms associated with husband and mothers-in-law relations, which in turn is mediated by gender equity (including intimate partner and in-law violence) and social determinants such as economic status and education.^112–117

Conclusion

The provision of respectful maternity care is an imperative factor in supporting improved maternal and perinatal outcomes. Concerns and principles that challenge the provision of RMC in South Asian nations are associated with resource-challenged environments (particularly in rural settings), gender equity, educational status, health workforce awareness, education and resourcing, culture, economy and other social determinants. Many of these factors are consistent with other settings; however, they are experienced and expressed diversely in South Asian contexts related to the specific characteristics of individual countries, cultures, and economies.

Sustained improvements in RMC demand strong policy actions, political will and appropriate well-funded programs to provide a well-educated and adequately resourced health workforce and counter economic disadvantage and gender inequities, privileging women’s choices and preferences.