Participants’ socio-demographic characteristics
The participants' socio-demographic characteristics included age, gravidity, number of living children, marital status, mode of delivery, and status of the baby. The participants' ages ranged from 18 to 44 years, with a mean age of 26. The number of living children varied, ranging from zero to seven children. Among the participants, 12 were primigravida. At the time of the interviews, four mothers had their babies in the neonatology unit, while one mother's baby had unfortunately passed away due to prematurity. The majority of the participants (two-thirds) had delivered their babies through normal vaginal delivery. In terms of marital status, 17 participants were living in cohabitation, five were legally married, and eight were single mothers (Table 1).
Table 1
Participant sociodemographic data
| Variables | Categories n = 30 | Frequency | Percentage % |
| Age | 18–20 | 7 | 23.3 |
| 21–35 | 20 | 66.7 |
| 36 and above | 3 | 10 |
| Gravida | Primigravida | 12 | 40 |
| Multigravida | 18 | 60 |
| Level of the hospital | District | 9 | 30 |
| Provincial | 12 | 40 |
| Referral | 9 | 30 |
| Living children | No child | 1 | 3.4 |
| 1 child | 10 | 33.3 |
| 2 children | 10 | 33.3 |
| 3 children | 9 | 30 |
| Marital status | Cohabitated | 17 | 56.7 |
| Married | 5 | 16.7 |
| Single | 8 | 26.6 |
| Mode of delivery | Vaginal delivery | 20 | 66.7 |
| Caesarian section | 10 | 33.3 |
| Status of the baby | Stays in neonatology | 4 | 13.3 |
| Stays with mother | 25 | 83.3 |
| Died | 1 | 3.4 |
The experiences and perceptions of mothers with regard to RMC related to three main themes and subthemes, namely, 1) Appreciated care with compassionate care and emotional support, autonomy and self-determination, timely care, privacy and confidentiality preservation, and enabling environment; 2) Perceived greatest care with respectful care meaning and happiness motives 3) Suggested strategies with women’s self-control, providers’ behaviors and caring leadership.
1. Appreciated care
Participants reported receiving compassionate care, free from mistreatment and violence. They expressed that their choices and preferences were respected throughout their recent childbirth experiences. They also reported receiving dignified and equal care, being attended to in a timely manner, and receiving the necessary services; their privacy and confidentiality were respected, and they received adequate information regarding their health status and care.
Compassionate care and emotional support
The participants expressed that they were treated with great empathy and compassion throughout their childbirth, and they reported receiving anesthesia before suturing vaginal tears and episiotomy. Participants who delivered by caesarean section were systematically provided with painkillers after delivery. Those who experienced pain during normal delivery were comforted; however, they were also aware that pain is a natural part of the childbirth process and that there were no specific interventions to reduce pain. They expressed that although they had to endure the pain, it is crucial for HCP to address all of a mother's concerns during childbirth to prevent her from becoming depressed.
“I don't know how I can describe that compassion I received here, it’s too much. After operation they start giving me perfusion and giving me pills, for reducing pain…. “It is the first time I gave birth, the first thing that ever causes pain is labor. However, when someone cares about you and ensures you that labour will progress like that or that, you feel energized.’’ Participant 12
“I heard that pain is necessary, you have to suffer and get well… our parents tell us that you have to suffer but you will be fine…Because there is nothing to reduce the pain, they (HCP) are saying be patient, you will get better.” Participant 26
Mothers expressed their appreciation for receiving dignified care and consistently reported feeling happy and satisfied with the services they received. HCP have shown patient HCPs showed patience to the mothers and were spoken to with comforting words, kindness, and politeness. The mothers did not experience any form of harassment, the HCP answered their questions without rudeness, and the HCP used gentle and soft expressions when interacting with them. Mothers expressed their gratitude for feeling valued and for the HCP staying close to them throughout the process. Gratitude from the HCP after pushing the baby is particularly meaningful. The mothers described the HCP as lovable due to their kindness and caring attitude.
“In healthcare providers, there was a girl who told me “mama, push, be patient, be patient darling, push; the contraction is in, and I felt happy” … the midwife comforted me and told me that "'all the tears you cried, I want to wipe them away". Now I am satisfied, I don’t know how I can say it, but it made me very happy” Participant 17
Autonomy and self-determination
Mothers reported feeling freedom during their childbirth experiences. They were not restricted from praying and were allowed to eat and drink; they had the freedom to walk, although within a limited space. The participants received equal treatment, there was no favoritism, and the hospital provided assistance to those in need, such as providing diapers for the baby. Mothers further stated that their choices and preferences were respected and felt supported by the HCP. Mothers who came without a transfer letter were also received with kindness, and the participants were not denied any service and received assistance every time.
“I told them my choice for family planning, and they immediately did it to me. I told them that I had decided to use the sterilization and I had to talk to the doctor in charge, and he did it for me.” Participant 28
Mothers reported that they received guidance on how to behave well during their childbirth experiences, including being advised on precautions to take and practicing self-control. They expressed happiness at being shown the placenta and receiving information about family planning and birth spacing. Some mothers were taught breastfeeding techniques and were encouraged to have regular meals to ensure an adequate milk supply. Additionally, some mothers were informed about the progress of their labor and encouraged to stay hydrated by taking fluids.
“Every time I needed the doctor, he came and told me that you are on this point, you are going to give birth well, relax. When I need him again, I called him until I gave birth, and she assisted me well, comforting me, telling me to push, and do it quickly without being rude to me but with kindness”. Participant 21
Mothers were informed and requested to provide informed consent, especially those who experienced caesarean section.
“Doctor always requested me “’Would you come for a check-up to see your labor progress? would you come for ultrasound to check if the baby is still alive?”, and I said yes. They told me that I am going to have surgery, they told me that you have to sign and your companion need to sign too, once you have signed, you have agreed to the surgery they are going to do for you”. Participant 13
However, most of the participants were not explicitly asked for verbal consent during routine examinations. Mothers reported that they did not feel the need to be asked for permission as trusted the expertise and abilities of the HCP. Mothers believed that it was their responsibility to follow the instructions given by the HCP. Nonetheless, participants expressed satisfaction with the practice of negotiation instead of coercion.
“When they take you to the examination bed, you are already aware that they are going to examine you…. well, when we are there, there is no need for permission because the doctors do what they were taught, or they were appointed. Whatever they do, you feel it’s right… “Listen, because of pain, you don't have to argue, you are even thinking the service provider is the one to recover you.”” Participant 18
Timely care provision
Most of the mothers expressed happiness and were impressed by the care received. They reported receiving the best services and being provided with all the necessary care. The HCP attended to them promptly and assisted them every time, even working overtime. In some hospitals, they first use available medicines, and mothers reimburse them later. The entire process was well organized, and mothers who arrived in critical conditions were given hope and excellent care. When the HCPs were unable to manage a case, they called experts for assistance. One notable example was when a very experienced midwife successfully helped a mother deliver vaginally despite indications for a caesarean section.
“The doctor gave me the best possible care like a good-hearted person and I feel very happy. I was so happy with what they did to me that I felt like giving her a car, poor me I don’t have it.…Whenever I wanted the doctor he came to me no matter what time he left, and he did not complain no matter how much I disturb him” Participant 21
Privacy/confidentiality preservation
Privacy was ensured as described by the mothers. They reported that they were not exposed to the public during the delivery process, and curtains or doors were closed to maintain their privacy. Mothers were allowed to be alone with the HCP, and cleaners were not allowed to enter the room during their stay.
“I'm thankful that these cleaners clean after you have given birth, none saw me. In the delivery ward, there are large curtains. Even the one who brought the materials, the doctor took them without letting him in…. When a person wanted something, the service provider went out and opened the curtains to listen to what he needed, but no one ever saw me” Participant 5
To ensure confidentiality, healthcare providers spoke quietly to the mothers. However, mothers reported that they could hear the health information of their colleagues. Nevertheless, mothers revealed that it did not matter to them, as they shared suffering from labour pain.
‘‘Even though sometimes, we are many here, I can hear the health information of my colleague mother and vice versa but since you are all suffering it doesn’t matter…it wouldn’t matter, because a colleague mother can’t share my information knowing how she was doing in labour and the way we shared sorrow of labour pain.” Participant 18
Enabling environment
Mothers reported that the birth companions were not allowed to stay with them in the waiting room, particularly in the delivery rooms, due to the structure of maternity rooms. However, most participants believe that birth companions are not helpful during the second stage of labour and that only HCPs are of assistance. Mothers narrated that birth companions are not health professionals, can become scared and discourage the mother. Participants also reported that birth companions are often busy buying medicines or doing other tasks outside and suggested that they should simply stay nearby and be available to bring the baby's clothes after birth.
“The birth companion couldn’t be of help, she wasn't a doctor to examine me, she was only responsible for standing there near the door and waiting for them to say that she gave birth and brought the baby's and mother’s clothes. I wouldn't want my birth companion to come in! because even now birth companion can see how you are doing and get scared and say that you are dying, but a healthcare provider, even if you are going to die, she keeps telling you to be patient.” Participant 26
Some mothers expressed satisfaction with the overall hygiene and cleanliness of the hospital. Cleaned toilets and regularly changed bedsheets made them feel satisfied. HCP often requests the cleaners to clean rooms multiple times. However, while some mothers were pleased with hygiene, others complained that the cleanliness in the toilets was insufficient.
“I am also happy that the hospital is clean, you sleep and they take care of your sheets and change them for you, and the shower and toilet are all clean without any problems. There was no problem, and the cleanliness was satisfying.” Participant 28
2. Perceived greatest care
Perceived respectful care meaning
Most participants understand RMC encompassing privacy, confidentiality, and freedom of movement during labor. They associate RMC with receiving timely and compassionate care, being spoken to in a soft and compassionate tone, being spoken kindly, politely, comforting her, actively listening, and staying close to her. RMC is seen as attending to the mother promptly, starting with those in critical condition. It involves receiving the mother well, showing patience, and inquiring about her well-being and that of her baby. Avoid abandoning, harassing, ignoring, or silencing her.
“The respect is when health service does not expose you in public, if you arrive at the hospital, you are cared for, when a service provider comforts you by saying, sorry mom, sorry Darling, with a smiling face, that is good…. When you are in the room you are in a private place, you are private if there is a door, they put on a curtain or close it, and you feel that you are alone with a healthcare provider and you feel you are respected.” Participant 17
“I feel respecting a mother is like, when she calls you, find you that’s how I feel, you let her (a mother) feel free.” ……. You should let a mother get up and walk… When a mother is in labor, she loves moving”. Participant 21
Mothers perceive professionalism as a crucial factor in providing RMC. They value love, compassion, and a sense of being valued by HCPs as important facilitators of RMC provision.
“What makes services providers to give me the good care it's love and compassion of healthcare providers had or that they value about their duty or maybe I had met doctors who knew what they wanted to do or who value their work “. Participant 18
Happiness motives
Mothers expressed that the fulfilment of their desires was the most important reason for appreciating and feeling proud of the services they received. Their primary wish and expectation were to have a normal delivery and a healthy baby while maintaining their own health. Additionally, mothers reported negative anticipatory feelings when seeking maternity care. However, HCP were available round the clock, closely monitoring and encouraging them, and instilling hope. Mothers appreciated that HCP were not preoccupied with phones, treated them with respect, offered comfort and support, and showed genuine concern for their well-being. One mother even expressed happiness at reuniting with a midwife who had assisted her in a previous delivery fifteen years ago. The perceived drivers of RMC, as reported by the mothers, included displaying love and professionalism, having a sense of responsibility, valuing both the work receiving appropriate training, and the critical state of the mother. The moment of getting their newborn baby was described as a transformative experience, overshadowing the pain of labor.
“It was truly great. The doctor was telling me to relax, don’t worry, there is no other reason, service providers told me that I want to give you a healthy baby because the doctor told me that “I will help you to give birth well. I didn’t have surgery. The thing that I am happiest about is that I saw a healthy child. For me, the first thing that makes me happy is to see a healthy child.” Participant 12
Remarkably, one participant who had experienced the loss of their baby due to severe prematurity expressed appreciation for the services received.
‘’ From when I arrived until I left down there, up to now, healthcare providers took good care of me though my baby passed away. If I was able to reward them, I would do it, I would repay them if I had something. They took care of me’’. Participant 24
Very few participants had positive expectations, such as hoping for a quick delivery or expecting to receive an ultrasound examination. Since most of the mothers were referred, some also anticipated a smooth and uncomplicated delivery, and all of these expectations were fulfilled.
“I saw that my baby was still alive in the womb…They just showed me her and told me she is a girl and ensured me that she is healthy, that make me happy’’. Participant 13
In general, participants reported having low expectations when seeking maternity healthcare due to the information received from their communities. They came with the belief that they would be disrespected and abused. Some were not aware of the current procedures and expected to receive the same treatment as in previous years. They anticipated being physically abused, insulted, scolded, subjected to fundal pressure, or unnecessarily undergoing a caesarean section. They also expected to be exposed naked in public and rudely spoken. They came with the fear of dying, being provoked, ignored, and being required to pay before receiving any service. However, participants experienced positive experiences. Some women were excited to give birth in a large building (on an upper floor).
“Before coming here, I have been told that some are beaten, I thank God they didn't beat me: I found it different, I don’t know what it is I’ve met a kind doctor.” Participant 16
3. Suggested strategies
To sustain RMC, mothers provided recommendations to service users, caregivers, and hospital management. Each level has its own responsibilities to fulfil.
Mother Self-control
Mothers reported that they have a responsibility to respect HCPs, follow the instructions given, use family planning to space their births, and regain confidence. To ensure lifelong sustainability of RMC, they suggested that their children should attend school and become future HCPs dedicated to providing quality services.
“Mothers should respect health care providers too; we should have few children. You know, mothers we always give birth, and you find that it’s stressful, and we have to plan for family”.Participant 30
Provider behaviours
Respondents advised service providers to sustain their courtesy, respect, and love toward the mothers. They should ensure the mothers' comfort and feel responsible in providing maternity care. Providing guidance to the mothers and maintaining the existing culture of timely care, mutual understanding, and respect were emphasized. It was advised for the providers to re-evaluate themselves, work diligently, and care for the mother as a human being. Doctors were urged to show respect to subordinates such as cleaners, and cooperation between HCPs and mothers was encouraged.
Mothers requested HCP to prescribe affordable medicine and avoid unnecessary prescriptions of surplus medical supplies. Providers should explain the progress of labor and communicate the results of examinations to the mother. It was suggested for HCP to talk to the mother while providing care, explain the labor process and progress, and assist mothers in having a normal delivery as much as possible. Additionally, it was advised for HCPs to prioritize triage and handle emergency cases quickly. Mocking multigravida women and unnecessarily retaining mothers in the hospital were discouraged. Security personnel at the gate were also advised to be briefed on respecting and allowing mothers to enter the hospital.
“Doctors should take care of patients as if it is their responsibility, not because it is their job, but because it is their responsibility”. Participant 11
HCP should strive to understand each other and avoid quarrels. One mother reported hearing HCPs insulting one another, while other HCPs complained about working overtime. Mothers advised that such behavior should be stopped, as the consequences could ultimately affect the service users.
“There is a time, a healthcare provider come and found her fellow didn’t fill the form accurately then insulted her… I hate insulting …. They were some health care providers, who were complaining that they are some who work days and nights, saying a lot of things like “why didn’t you give me my off.” Health care providers came saying “I am fed of this, I may leave this job, look, I did a day shift, I didn’t take a break, they want me to fill out these while my working hours were finished.” …, if a health care provider claimed to her colleague, she is tired, you could listen to her.Participant 24
Caring leadership
Mothers recommended to the hospital leadership to train supervise, to innovate ways to motivate the HCPs. Participants emphasized the importance of publicly showing gratitude to the HCP and ensuring timely payment of salaries. Increasing the number of HCPs, as well as providing sufficient labor monitoring equipment, are suggested. Mothers also highlighted the need for continuous training for HCPs, including new graduates and students, and providing mentorship to ensure the delivery of quality care. They recommended that future HCPs be taught to prioritize patient care and love for their patients. Conducting campaigns and workshops on RMC was seen as beneficial. Building or renovating hospitals with spacious rooms and an adequate number of beds to avoid mothers and newborns sharing beds was another important suggestion. Last, they emphasized the importance of striving to have a good reputation in the community.
“Doctors leaders would come to their colleagues and perhaps thank them and tell them that maybe all mothers who gave birth in this certain time are happy and I think it will motivate them to continue doing well”. Participant 15
Some respondents recommended that the hospital provide food to mothers whenever possible, especially for those who come from a distance and may not have money to buy food from the canteen. In terms of hospital bill payments, it was suggested that priority should be given to providing care to the mother first, with payment arrangements made afterward. They also recommended that the cost of services should be proportionate to the service received and that prescribed medications should be covered by health insurance. To address the issue of mothers being retained in the hospital due to an inability to pay, respondents suggested that the hospital and the mother could enter into a contract allowing for gradual payment. Participants emphasized the need to improve hygiene and cleanliness in the hospital environment. Regarding personal hygiene, some mothers expressed resistance to using diapers during labor, fearing harm to their babies. Mothers also raised concerns about overcrowding in hospitals, where two mothers may have to share one bed.
“Another thing is that they should add hygiene and cleanliness, and they should clean properly that mothers won’t acquire illness.” Participant 16