Respectful maternity care: Disconnect between perspectives and practices of midwives from a referral hospital in Kampala, Uganda.


 Introduction: Disrespectful and undignified care during childbirth is a global challenge, particularly in less developed countries. Despite the increase in health facility births, women continue to suffer from disrespect and abuse during childbirth. This practice counters the efforts to encourage women to deliver in health facilities by a skilled birth attendant as a strategy to reduce maternal and neonatal mortality. The purpose of the study was to explore midwives' understanding of respectful maternity care and observe how their practice conforms to this concept. Methods: We conducted a qualitative study combining one-on-one interviews and observation methods of data collection. In-depth interviews were conducted with 17 midwives and 20 observations were done. Audio-recorded data were later transcribed verbatim and analyzed using the content analysis method. Observation data was summarized into a table 2 below.Results: Midwives understood respectful maternity care (RMC) as treating women with respect, dignity, politeness, providing information to clients, and ensuring privacy and confidentiality. However, there was a discrepancy between their understanding of RMC and what they practiced. They also lacked an in-depth understanding of the domains of RMC. Conclusion: There is a need to strengthen midwife's knowledge and skills to enable them to provide respectful maternity services. We recommend in-service training and mentoring to equip midwives with knowledge and skills to offer RMC. Also, RMC should be integrated into pre-service curricula for midwifery and nursing training in Uganda. Furthermore, efforts should be put in to strengthen health systems, and support healthcare providers to provide RMC. More research is needed into locally relevant solutions to promote respectful maternity care.


Introduction
Globally, maternal mortality declined by 35% from 2000 to 2017 [1]. However, Sub-Saharan Africa and Southern Asia continue to be the most affected regions contributing about 86% of the global maternal deaths in 2017 [1]. The above global reduction in maternal mortality is partly due to the increase in skilled birth attendance, mostly from low-income countries [2][3][4]. Despite this impressive progress, in both high income and low resources settings, pregnant women continue to suffer from disrespect and abuse during childbirth, and this is countering efforts to encourage pregnant women to give birth in health facilities under the care of a skilled birth attendant [5][6][7]. The World Health Organization recommends respectful maternity care (RMC) 'which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy, and con dentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth [8]. Respectful maternity care is an essential dimension of quality of health care that ensures practice that aligns with international human rights standards [9] and the universal rights of women and new-borns as outlined in the respectful maternity care charter [10].
In the past decade, disrespect and abuse during childbirth have attracted a lot of scholarly interest globally. Several studies have described various forms of disrespectful and abusive care experienced by women during childbirth. These include physical and verbal abuse [11][12][13][14], stigma and discrimination [15], and neglect and abandonment [16]. Most studies in this eld focused on experiences and perspectives of women, their partners, community members, and health providers [11,[17][18][19][20][21][22]. Recently a few observational studies [7,[23][24][25] have been conducted to examine the practice of health professionals concerning RMC.
While Uganda has made signi cant progress in maternal health care, with 73% deliveries occurring in a health facility and 74% birth being attended by a skilled person, there is certainly room for more improvement [26]. Previous studies report that fear of being neglected or maltreated by health workers [27], high level of verbal abuse and poor communication [28] are some of the barriers that deter women from attending public health facilities in Uganda and this negatively impact access to skilled birth attendance. To address these challenges and start the journey to a positive childbirth experience [8] for Ugandan women, it is vital to examine midwives' understanding of RMC. The purpose of the study was to explore midwives' understating of respectful maternity care and observe how their practice conforms to this concept.

Study design
This was a qualitative study combining one-on-one interviews and observation methods of data collection.

Study setting
The study was conducted in in a referral hospital in central Uganda. According to the Human Resource records of the hospital in 2019, the hospital employed a total of 280 midwives working in different areas of maternity care. Twenty-eight midwives were allocated in the public labor ward where the study was conducted. This labor ward has an average of 50 births daily. .

Study population
The participants were midwives working in the labor ward at the time of the study. Midwives working in the labor ward who were either on leave during data collection or did not consent were excluded from the study.

Sample size
Twenty-ve midwives were approached and 20 of them agreed to participate in the study. Data saturation was achieved after interviewing 17 midwives and therefore three of those who consented were not interviewed. For the observations, all the 20 midwives who consented were observed providing care to women during labour and childbirth.

Data collection process
We used convenience sampling to select study participants who were available and could describe their perspectives. A list of midwives working in the labour ward and their contacts, cadres, and years of experience was obtained. The midwives were called by phone and invited for a meeting to talk about the study. During the meeting, the midwives were given details regarding the study and written informed consent was obtained from 20 midwives who were willing to participate in the study. After consent, an interview date and time was scheduled according to participant's convenience. All interviews were conducted by M.A. in English using an in-depth interview guide. Interviews were conducted in a quiet room at the facility and audio recorded. The interview guide contained closed-ended questions that were used to collect sociodemographic characteristics, and open-ended questions to assess; 1) understanding of RMC (What does respectful maternity care mean to you?), 2) enablers (In your unit, what things help you to provide RMC to women during childbirth?) and 3) barriers (What things hinder midwives from providing respectful maternity care as you have described above?) to RMC provision. Probes were used to generate more in-depth information from the participants on speci c issues of interest.
An observational checklist was developed from the RMC typology as described by Bowser and Hill [30]. This framework has seven domains of RMC namely; 1)non-abusive care, 2) consented care, 3) digni ed care, 4) con dential care, 5) non-discriminative, 6) continuity of care and 7) non-detention at the health facility due to lack of funds.. The domain of non-detention at the health facility was not included because the study was conducted in a public health facility where care is free of charge.
The observers were two midwives working at a different unit within the hospital. The observers were trained to use the observational checklist and encouraged to write eld notes of actions that were not captured to give a clear picture of events. The participants were observed providing care to one mother from the time of admission until childbirth. The observer did not participate in any of the caregiving activities. During the initial assessment of the mother, some of the actions observed included; whether the midwife greeted the woman in a respectful manner, encouraged her to have a support person present, explained procedures before proceeding, informed woman of ndings, and asked if she had any questions. While during labour and child birth, observers looked to see if; the midwife explained what would happen during labor to the woman, encouraged the woman to consume food or drinks, encouraged or assisted the client to ambulate and assume different positions, and supported the woman in a friendly way and draped her during delivery. At the end of each observation, observers recorded open-ended comments about the quality of care observed and any other important observation to enhance the understanding of some of the answers in the checklist.

Data management and analysis
Data analysis began from the point of data collection and followed a detailed process. The audiorecorded interviews were transcribed verbatim. The transcripts were checked against audio recordings to ensure no information was missed out during transcription. The interview transcripts were printed out for ease of analysis. Transcripts and audio versions of the data were stored on a password-protected computer and were available to only the research team members. Content analysis by Shannon, 2005 [29] was used to analyse data from the in-depth interviews manually. The interview transcripts were read and re-read by the rst four authors to independently come up with codes. There was constant comparison of codes among the four authors. Where there was disagreement, the coders re-read transcripts, re ected on the meaning units to agree on the codes. The codes were then categorized according to their similarities and differences. Bowser and Hill RMC typology was used to arrange the categories into themes [30].
For the observations, both the checklist observations and the written notes were mapped onto the thematic areas of RMC from the interviews.

Ethical considerations
Ethical approval to conduct the study was obtained from Makerere University, School of Health Sciences, Research and Ethics Committee (SHSREC: 2018-051). Administrative clearance was obtained from the Research Ethics Committee of the referral hospital (MHREC: 1550) and the hospital. Permission was also sought from the ward in-charge of the public labor ward for data collection. Written informed consent was obtained from the mothers and the midwives. Participation was voluntary and all the interviews were conducted in private settings to ensure participant's con dentiality and using serial numbers as identi ers for the transcripts and observations

Socio-demographic characteristics of participants
The average age for the study participants was 34 years. Nine participants were Anglicans by religion and Baganda by the tribe. More than half of the participants had a diploma in midwifery quali cation. The average years of experience were 11 years. Details of sociodemographic characteristics are presented in Table 1 below. Midwives understood RMC in various ways. They viewed RMC as respectful and ethical interactions or relationships between the woman and the midwife. This relationship was reported to start right from antenatal through labor until the postpartum period.
"I look at respectful maternity care as inter-relationship between mother and midwife in an ethical form where a midwife considers the mother's rights." IDI, participant 13.
"It would mean the relationship and interaction between a midwife and the mother who is pregnant from the time the mother has conceived, during antenatal, during labour, and after delivery." IDI, participant 1.

Non-abusive care
Participants did not regard non-abusive care as part of RMC. In the in-depth interviews, none of the participants articulated non-abusive care as one of the components of RMC. The kind of physical abuse noted during the observation part of the study is, therefore, not surprising. For example, a midwife was observed slapping a woman for not complying with instructions, another midwife sutured a tear without giving lignocaine, and another one performed an episiotomy without local anesthesia. In yet another incident, a midwife was seen piercing a woman's thighs with the suturing needle. These are incidences that indicate abuse of women's right to freedom of harm and ill-treatment during the process of delivery.
Consented care Participants understood consented care as providing women with information about what was going to be done as well as an explanation of the process of labor. This is evidenced in the quotes below.
"At the same time, you let her introduce herself to you. Then you tell her about what is going to happen, all the process (detailed information)." IDI 12 "Explaining everything to the mother, giving full information about labor process." IDI participant 13 Participants' understanding of consented care was validated during observations as midwives were seen providing information to the clients in an open and friendly way. They also encouraged clients to ask questions. However, consented care, as de ned in the literature, is beyond just providing information; it includes aspects such as seeking permission and consent for procedures such as vaginal examinations, episiotomy, cesarean section, and other procedures. The latter conceptualization of consented care was barely observed from the participants of this study (refer to Table 2 for more details). Midwife explains what will happen during labour to woman 1 (5) Midwife encourages woman to consume food and uids during labour 17 (85) Midwife encourages or assists mother to ambulate and assume different labour positions

(70)
Whether the midwife used a partograph for monitoring labour 0 (0) Midwife supports mother in a friendly way during labour 7 (35) Midwife drapes client before delivery 4 (20) Midwife applies active management of third stage of labour 15 (75) Midwife applies the immediate essential new born practices 18 (90) Midwife screens for complications in both mother and baby 18 (90) Con dential care The participants in this study had a general understanding of what con dential care is, as illustrated by the quotes below.
"If she has come in labor, provide con dentiality, privacy so that she feels comfortable to open up about her issues." IDI participant 12 "A spacious room with privacy enables me to provide respectful maternity care." IDI, participant 10.
However, structural and system factors seemed to impede the provision of con dential care. From the observations, the delivery rooms had no curtains or screens to provide privacy to mothers during labor. Besides, the labor ward set up was in such a way that a midwife would be overheard by others while communicating with a mother, which violates con dentiality.

Digni ed Care
Midwives described digni ed care as treating clients with respect, humility, and politeness. They believed in building friendly relationships with clients through creating rapport and showing understanding and tolerance while interacting with women, especially during labor. Others described it as making mothers feel comfortable, for example, by providing a bed and reassurance. These descriptions are captured in the quotes below.
"If she has come in labor, welcome her, greet her, and introduce yourself to her and let her introduce herself to you so that she feels comfortable to open up about her issues." IDI, participant 9.
"RMC is the care the midwife gives to a mother that involves respect, humility, and politeness… During labor and delivery, these mothers come in pain; they can say anything or behave in any way, so they need to be understood." IDI, participant 7.
However, during the observations, midwives depicted both positive and negative aspects of digni ed care they described above. Some midwives were calm and friendly while interacting with the mothers. They greeted mothers at arrival, listened, and supported them during labor. On the other hand, other midwives were not respectful. They were rude as they scolded, shouted, and ignored mothers when they needed help. In some instances, midwives were not patient and had a negative attitude towards mothers.
"If you do not want to be repaired, I don't care. It is your marriage that will break. (Midwife yelled)" Direct observation 2 "I don't have time to wait for slow people like you, let me leave you to take your time (The midwife called in another client for examination and left the mother waiting)." Direct observation 1 Non-discriminative care Only one midwife described this domain. She viewed RMC as providing non-discriminatory care, where all mothers can get equal treatment. This is illustrated in her quote below.
"When mothers come in labor, I should not segregate them by tribe, religion, or anything." IDI, participant 15 During the direct observation, mothers were treated on a rst-come, rst-serve basis. However, when there was a shortage of supplies at the labor ward, the mothers who could not afford to buy the supplies had delayed or did not receive care

Continuity of care
Midwives also viewed RMC as being able to document and monitor mothers and babies during care. The midwives emphasized the importance of being knowledgeable, having tools to monitor mothers, and the ability to provide timely collaborative care. They pointed out the willingness and availability of other health workers as critical to delivering RMC.
"….it is proper monitoring of mother and baby's condition during labour using a partograph, and proper documentation; in case of deviation from normal, the doctor is informed timely so that appropriate action can be taken to save the mother and the baby on time." IDI, participant 15.
As much as midwives mentioned monitoring mothers using partographs during labor, none of them was observed using a partograph. There was also a delay in delivery of care whereby a midwife delayed preparing a mother for cesarean section after a decision had been made and another one delayed to identify the need for resuscitation for a newborn (refer to Table 2).
Theme 2: Barriers to respectful maternity care Midwives mentioned potential barriers to RMC provision such as; shortage of staff, lack of equipment, sundries, and medicine, inadequate resources, low salaries, client-related factors, knowledge gap, and lack of teamwork. The sshortage of staff, for instance, leads to working for long hours, which compromises their ability to provide RMC.
"Shortage of staff; you nd that in our labor ward, midwife to mother ratio is 1midwife: 20 mothers. Remember, we work from 8.00 am to 8.00 pm, this becomes so distressing." IDI, participant 7.
"When you are exhausted, you cannot be able to give proper care; that is, you will not explain procedures to the mother, and she may refuse to be worked upon." IDI, participant 14.
Midwives also said that lack of equipment, sundries, and medicine hinders the provision of quality and digni ed care.
"….there are no sundries in the hospital, and so I have to ask mothers to provide, and sometimes they do not have money, or they may just keep silent because of pain. This makes the midwife change colors (become angry) and tone of voice due to anger and ends up barking at the mothers." IDI, participant 6.
According to midwives, the health facility did not provide adequate space for private and con dential care.
"… every patient has a right to privacy, but for the case of our labor ward; its setup, it's very di cult for a midwife to maintain privacy." IDI, participant 2.
Low salaries also demotivate midwives, which compels them to get other jobs. So that by the time they report for duty, they are exhausted and may not be able to provide RMC.
"…due to the little salary, you may opt to get a part-time job so that you increase on your income, by the time you come from the part-time job you are already tired, which will make you have a bad attitude towards the mothers." IDI, participant 15.
The other barrier cited by participants was the inability to communicate to clients due to challenges such as language, deafness, and mental illness.
"At times, it could be due to language barrier or physical impairment such as the deaf and the dumb who cannot speak hindering midwives from offering RMC. Sometimes midwives receive mentally ill women who cannot understand any explanations hence becoming uncooperative." IDI, participant 16.
Some participants stated that negative attitudes of clients towards midwives make them uncooperative, which hinders the provision of RMC.
"Some of the clients themselves have a poor attitude towards the midwives, and this makes them uncooperative. When a mother is biased on a midwife, she will do the opposite of what you instruct her to do." IDI, participant 12.
Midwives cited the knowledge gap as a barrier to providing RMC. According to the participants, the lack of continuous professional development has contributed to the knowledge gap on the current standard of practice.
"…, lack of Continuing Medical Education (CME), because if we had CMEs, they would keep on reminding us of what to do; we could not forget what we are supposed to do. However, you nd that it takes too long to have them, and when they plan for them, very few people attend because if we are three on duty, how will we separate ourselves, and yet we have four stations in the labor ward." IDI, participant 6. Findings from the observational checklist Findings from the observational checklist were tabulated with frequency and percentage and are presented in Table 2 below. The actions of respectful maternity care performed by majority of participants were; encouraging the mother to have a support person (12/20), encouraging mothers to consume foods and drinks (17/20) and assisting the mother to ambulate or assume different positions during labor (14/20). On the contrary, use of the partograph to monitor the progress of labor (0/20), explaining what will happen in labor to the mother (1/20), asking the mother if she has questions (1/20), and explaining procedures before performing them were least done by the participants (3/20).

Discussion
The aim of this study was to assess the perspectives and practices of midwives concerning respectful maternity care (RMC). We found that participants in this study did not have a solid understanding of the concept of RMC. Findings from in-depth interviews re ected a shallow understanding of the various domains of RMC, as presented by Bowser and Hill [30]. In several domains, there was a disconnect between what the participant mentioned and the observed practice. Moreover, analysis of the interviews did yield content that re ected participants' understanding of non-abusive care as a domain of RMC.
From interviews, midwives described consented care as giving detailed information to mothers in a friendly way, explaining each procedure performed, and providing feedback. However, during the observations, only a few participants were seen doing what they had stated in the interviews. It was observed that most midwives did not seek consent before performing procedures such as episiotomies and vaginal examinations. This nding is consistent with what has been observed in other studies. For example, Bohren and colleagues found that many women had not consented to episiotomies and cesarean section despite receiving the procedure [7]. In another study conducted in Tanzania, many participants narrated experiences of forceful vaginal examinations which were conducted without seeking consent [31]. These ndings highlight practice that is inconsistent with the human rights approach that requires effective and proper application of informed consent during childbirth, there is a need to change practice to respectful and acceptable ways [32].
In this study, non-abusive care as a domain of RMC did not emerge from the analysis of the interviews conducted. It was, therefore, not surprising that some of the participants were observed verbally and physically abusing women during childbirth. Some midwives were seen suturing women without lignocaine, slapping, or piercing a woman's thighs. In other cases, participants were rude to patients, and others scolded or shouted at the women. These ndings con rm reports from earlier studies conducted in Uganda [14,28]. Similar instance of poor communication between health providers and women, as well physical abuse, are common occurrences in other African countries [7,23,33,34]. The widespread nature of the phenomenon of disrespect and abuse of women during childbirth does seem to suggest deeprooted structural and socio-cultural challenges inherent in many societies. Thus, remedying it may require examining what Sen and colleagues call the drivers of disrespect and abuse in childbirth, which are intersecting social and economic inequality, and the institutional structures and processes that frame health practice [35].
We found that the participants from this study generally appreciated the need to provide con dential and private care as a requirement for RMC. However, structural and system factors such as lack of screens and curtains impeded their ability to provide RMC. This nding resonates with those from a study conducted in Iran [36] agrees with what has been reported in other African countries [21]. Indeed, several studies have pointed out the lack of adequate supplies, poor staff remuneration and shortages, and structural and institutional bottlenecks as majors challenges that hamper the provision of respectful maternal care [7,27,33,37,38]. Therefore, addressing disrespect and abuse will require system-wide efforts that support healthcare providers to deliver RMC. There is a need to structure health systems in a way that promotes respectful maternity care [39], and this will require enormous investment.
Only one participant mentioned non-discriminatory care as an important aspect of RMC. However, we observed that clients were treated on a rst-come-rst-served basis. Nevertheless, there were incidences when care was delayed or missed because the patient was unable to provide the supplies that she was required to buy. This system related problem may result in discrimination based on nancial grounds, which undermines trust and provision of quality care. The study site was a government-aided facility that provides services free of charge, and most clients come expecting free services. Therefore, being asked to buy what you expect to nd in the health facility is psychologically distressing and discourages future visits to public health facilities.

Study limitations
The midwives were aware that they were being observed, and some could have modi ed their interaction with women according to what is expected. However, efforts were put in to reduce modi cation of behavior for example, midwives were not aware of what topics and items were on the checklists, and observers were recruited from other units other than general labor ward to minimize the effect of personal and professional relationships. This study reports both respectful and non-respectful maternity care which requires change and maintaining some elements for quality delivery of maternity services.

Conclusions And Recommendations
Midwives understood respectful maternity care (RMC) as treating women with respect, dignity, politeness, providing information to clients, and ensuring privacy and con dentiality while providing care. However, there was a discrepancy between their understanding of RMC and what they practiced. They also lacked an in-depth understanding of the domains of RMC. We recommend in-service training and mentoring to equip midwives with knowledge and skills to provide RMC. Also, RMC should be integrated into preservice curricula for midwifery and nursing training in Uganda. Also, efforts should be taken to strengthen health systems, and healthcare providers should be supported to provide respectful maternity care. More research is needed for locally relevant solutions to promote respectful maternity care. sought from the ward in-charge of the public labor ward for data collection. Written informed consent was obtained from the mothers and the midwives. Participation was voluntary and all the interviews were conducted in private settings to ensure participant's con dentiality and using serial numbers as identi ers for the transcripts and observations

Consent for Publication
Not applicable Availability of data and material The datasets used and /or analyzed during the current study are not publicly available due to some privacy reason, but are available from the corresponding author on reasonable request.

Competing interests
The author(s) declare that they have no competing interests. Authors' contributions MO designed the study, collected and analysed the data, drafted the paper; CO contributed to the design of the study, analysed the data, drafted the paper and reviewed the paper. CPO contributed to the design of the study, analysed the data, drafted the paper and reviewed the paper; AN contributed to the analysis and reviewed the paper; EA contributed to the reviewed the paper and SNM drafted the paper and reviewed the paper.