Study design
A systematic review will be undertaken to critically assess and evaluate available research studies that address the interventions and strategies implemented to eliminate the mistreatment of women in maternity care and facilitate respectful maternity care.
Review method
Studies that have evaluated the effects of health interventions to prevent mistreatment and enhance women's safe and respectful maternity care will be reviewed according to the Preferred Reporting Items for Systematic and Meta-Analysis-2020 (PRISMA-2020) guideline [23]. The findings of the selected research studies will be described and evaluated, and a meta-analysis will be undertaken. The overall aim is the critical evaluation of the state of knowledge on respectful maternity care health practices.
Criteria for selecting studies for this review
Studies will be selected according to the PICOSS (participants/ population, intervention, comparisons, outcomes, study designs, and settings) by following the following inclusion and exclusion criteria.
Inclusion criteria
Studies in English at any date will be included when:
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The intervention was designed to prevent or decrease mistreatment of women during maternity care (physical abuse, verbal abuse, sexual abuse, privacy, non-consented and non-confidential care, stigma/discrimination, abandonment, detention)
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Interventions were intended to enhance respectful maternity care
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The intervention was designed to impact the experiences of women during maternity care in health facilities
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The research has been conducted in randomised controlled trials, observational longitudinal pre- and post-studies
Exclusion criteria
Studies will be excluded when:
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They are qualitative investigations, book chapters, case reports, letters, opinions, and editorials
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A study does not report to the comparison of outcome rates between interventional and comparator groups
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Studies were not designed primarily to prevent mistreatment of women or respectful care enhancement, but were instead intended to increase service utilisation and equity
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The intervention is primarily designed to decrease specific intrapartum interventions
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Articles are found to be fraudulent or may for other reasons have been retracted since publication will be excluded from systematic review and meta-analysis.
Population
The review will consider studies that have investigated the effectiveness of interventions that were applied across service and/or a community, health service providers and/or a health facility for the prevention of mistreatment of women and ensure respectful maternity care for all women in low-and middle-income countries during maternity care (during pregnancy, birth, and postnatal care).
Interventions
The review will consider studies that evaluated the effectiveness of RMC interventions aimed at minimising disrespect and abuse in maternity care. Interventions that aimed to reinforce the validity of respectful maternity care may include studies regarding facility-based quality improvement processes, or studies reporting on the effectiveness of interventions. Examples of interventions could be those that, adhered to RMC guidelines and policies, provided RMC training, ensured accessible essential equipment, medicines and health supplies, and when facilities supported linkages between the facility and the community.
Comparators
The effectiveness of RMC interventions will be compared to usual maternity care provided in health facilities in the absence of any interventions at an individual, health facility or community level related to improving respectful care or preventing disrespectful and abusive care.
Outcomes
The primary outcomes will be mistreatment of women (observed by investigators or self-reported by women). It is important to note that the mistreatment of women has various interpretations across the world because the standard of health care and the way that health care is organised and experienced differs around the globe. For the purpose of this systematic review mistreatment will include the explicit experiences of verbal abuse, physical abuse, neglect, stigma and discrimination, poor communication or other forms of mistreatment related to health care providers or health care facilities, as described in comprehensive global systematic review conducted by Bohren and et al. [24].
The next potential outcome will be the provision of respectful maternity care (RMC). Respectful maternity care has been provided when health care providers deliver maternity care which is underpinned by the ethical principles of non-maleficence and beneficence. Using findings from systematic reviews, Shakibazadeh et al. [25] developed twelve domains of RMC to clarify what constitutes respectful care. These twelve domains will be used as guiding measures of respectful maternity care.
Types of studies going to be included in review
Randomised, non-randomised controlled and observational studies identifying the effectiveness of respectful maternity care interventions focusing on the prevention of the mistreatment of women or enhancing respectful maternity care will be included in the review.
Search methods for identification of studies
The search strategy aims to retrieve both published and unpublished studies. A three-step search strategy will be utilised. An initial search of PubMed and CINAHL will be undertaken, followed by an analysis of the text and words contained within the journal title and abstract, and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across a variety of databases and other sources, including EBSCO Nursing/Academic Edition, African Index Medicus, African Journals Online (AJOL), Scopus and Google Scholar. Thirdly, a manual search of the reference lists of all identified papers and reports will done to locate any additional studies citied within the identified papers.
Only studies written and published in English will be considered for inclusion. A search for unpublished studies will also include ProQuest's dissertation and thesis database, grey literature from search engines such as Google, and finally those of various universities databases. Keywords will include 'mistreatment', 'disrespect and abuse', 'maternity care', 'antenatal care', 'birth', 'postnatal care', 'interventions', 'programs', and 'policy'. The details of PubMed search strategies are given in a supplementary file (S1).
Study selection
The results from all bibliographic searches will be exported into Endnote version X9 [26], which will be used to manage and store relevant studies. Citations will be exported to Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). Duplicates of identified studies will then be removed in Covidence. Both software packages used are licensed by the University of Technology Sydney.
The title and abstract of all remaining studies will be assessed for their relevance based on inclusion and exclusion criteria by HK and VS. Those articles considered potentially relevant to the aims of this systematic review will have their abstract read to assess for the utility of full-text screening. Therefore, any study or report noted to be relevant will be read in full and determined whether suitable for the final selection. The screening process as specified by the Studies screening PRISMA 2020 flow diagram [23] will be used. This diagram is presented in figure 1.
Data collection and analysis
Assessment of methodological quality
Papers selected for retrieval will be assessed independently by two reviewers to ensure methodological validity. The standardised critical appraisal instruments from the Critical Appraisal Skills Program (CASP) and Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) will be used. When a difference of opinion occurs between the two reviewers, the issue will be resolved through them discussing the specific study, and a consensus will be reached with the involvement of a third reviewer, AS.
Data collection
Data will be extracted from papers using a standardised data extraction tool from JBI-MAStARI by two independent reviewers within the research team. The data extracted will include specific details about the study population, interventions used, study methods and outcomes of significance in relation to the review question and objectives.
Data synthesis
The papers will be pooled in a statistical meta-analysis using Stata version 15 meta-analysis. All results will be subject to double data entry. When reviewing RMC interventions that have been aimed at preventing mistreatment of women or improving experiences of RMC, different categories of interventions will be combined in a single meta-analysis to address the question: 'what is the effect of RMC interventions on reducing or preventing mistreatment of women?'.
The effect sizes will be expressed as odds ratio for categorical data (mistreatment among interventional groups compared to control/usual care groups) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and I-squared and explored using subgroup analyses based on the study designs, types of RMC interventions (community intervention, health system intervention, health facility or individual health care providers targeted interventions). If the results of sub-group analysis indicated considerable heterogeneity via an I-squared of greater than 20%, the random effect model will then be reported. Where statistical pooling of variables is not possible the findings will then be presented in description form, including the use of tables and figures to aid in data presentation where appropriate.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence and a Summary of Findings will be created using GRADEPro.