Case for improving respectful care: results from a cross-sectional survey of person-centred maternity care in rural South Africa

Introduction

At the global level, almost all women (88%) are now receiving at least one antenatal visit and a substantial majority (78%) deliver in health facilities.1 Attention has shifted from an emphasis on increasing the utilisation of maternity services to a more nuanced focus on enhancing the quality of care provided. This shift has been accompanied by growing evidence of the poor treatment of women during facility-based childbirth.2–4 There have also been progressive changes to terminology from more negative terms such as obstetric violence and mistreatment5 to more positive framing of respectful and person-centred maternity care (PCMC).6 The WHO intrapartum care guideline of 2018 recommends respectful maternity care (RMC) for all women, which is care that maintains ‘dignity, privacy and confidentiality, ensures freedom from harm and mistreatment and enables informed choice and continuous support during labour and childbirth’.7

Disrespect and abuse in maternity services in South Africa (SA) has been well described over several decades and while not unique to SA, research has found that it is deeply rooted in the country’s complex sociopolitical landscape.8 An unequal healthcare system, inherited from the apartheid era, is characterised by maldistribution of health workers and resources between the public and private sector.9 Much of the research on the quality of maternity care in SA has used qualitative research designs and focused on urban-based midwife obstetric units (MOUs), a model where midwives provide care for low-risk women in stand-alone maternity units. One of the first post apartheid research studies (published in the late 1990s) documenting women’s experiences of maternity care described nurses’ verbal and physical violence towards women as a means of creating social distance and maintaining a relationship of power.8 Other neglectful and abusive practices commonly reported by mothers in SA include unfriendly provider attitudes, poor communication, failure to inform women about their care and lack of privacy but may also include physical and verbal abuse.10 11 The majority of nurses and midwives in SA are women living in environments where they may themselves be experiencing gender-based violence.8 12 A recent qualitative study conducted in MOUs in Cape Town described patient neglect as a form of normalised violence within maternity settings.13

Three decades of research on poor quality of maternity care in SA and increased global attention on the importance of the experience of care as a component of quality maternity care7 have led to revisions in national guidelines and policies to specifically include a focus on respectful care. The SA maternal, perinatal and neonatal health policy, updated in 2021, includes a specific policy statement on RMC.14 Similarly the fourth edition of the guidelines for maternity care in SA published in 2016 states that ‘Health workers administering care to pregnant women must demonstrate respect and a genuine interest in their clients and avoid an arrogant, rude or judgemental attitude. This applies even in the context of a poor working environment or perceived unsafe practices of certain pregnant women’.’15

An additional factor influencing the policy shifts towards improved experience of care is the high burden of medicolegal claims in the public sector, the majority of which are obstetric related and amounted to R77 billion (approximately US$4 billion) in 2023. Disrespectful care and poor clinical care are closely linked, for example, when mothers are left unattended for long periods and feel unable to voice their concerns, this leads directly to poor outcomes for mothers and newborns.16 In addition, women and families who have not received explanations about an adverse outcome may be more likely to litigate. Implementing the South African patients’ rights charter, which states that patients have the right to care by healthcare workers ‘that demonstrates courtesy, human dignity, patience, empathy and tolerance’’17 is one of the proposed solutions to the obstetric medicolegal crisis.18

There has been very little quantitative measurement of women’s experiences of care during childbirth in SA and a lack of focus on rural contexts where challenges to the provision of quality maternity care are even greater than urban areas.19 Furthermore, in KwaZulu-Natal province, one in three women in the public sector (34.5%) has a caesarean delivery. This is the highest rate in the country with the national public sector rate for 2020 being 28%.20 Unlike most other countries in sub-Saharan Africa, there is good access to caesarean delivery in SA with 97% of births being attended by a skilled birth attendant.21 However the caesarean delivery rate is far higher than the WHO-recommended rate of 10%–15% of all births22 and there are concerns about the safety of caesarean delivery in the public sector with the caesarean delivery case fatality ratio in 2021 being 204 deaths per 100 000 caesarean deliveries compared with a total maternal mortality ratio of 148 per 100 000 births in the same year.20 To date, there has been no research measuring women’s experiences of caesarean delivery in SA. This research aimed to provide a quantitative, baseline measure of PCMC in two rural districts in order to inform the future development of a participatory learning and action intervention to improve RMC.

Methods

We undertook a cross-sectional survey using the PCMC tool developed by Afulani et al.23 This tool, and the derived PCMC scale, was developed in a rural and urban setting in Kenya23 and subsequently applied in India and Ghana.24 The development of the scale in Kenya followed standard procedures for scale development25 including psychometric analyses to assess the validity and reliability of the individual items. The final tool with a 30-item scale and 3 sub-cales correlated with global measures of satisfaction with maternity services.23

This survey was the first application of the PCMC tool in SA. It was undertaken between October 2022 and February 2023 to obtain a baseline measure of PCMC, as part of a before-and-after evaluation design for a facility-based participatory learning and action intervention with maternity unit staff.

Results

Table 1 shows the demographic characteristics of respondents by mode of delivery. The mean age was approximately 26 years with 15% of the sample being young women (16–19 years) and the average parity was two children. Less than a quarter of women were married or living with a partner and approximately half of the women had completed secondary school education. There was no significant difference between any demographic characteristics by mode of delivery. Women who had a caesarean delivery were more likely to have a delivery conducted by a male provider, by a doctor and during daytime hours, compared with women who had vaginal deliveries.

Online supplemental table 1 shows the distribution of all the PCMC variables by mode of delivery. Just over two-thirds of women in both groups felt that they were treated with respect all the time. There were several areas where PCMC was poor irrespective of mode of delivery. Around one-fifth of women reported verbal abuse at least once and 7% reported any physical abuse. A little over half of women felt that their health information would be kept confidential all of the time, less than 15% of women were allowed to have a companion with them during labour or delivery and less than half of women felt that they could completely trust their providers all of the time. Less than half of women reported that there was water at the facility all of the time. Perceptions of overcrowding were common with 55% of women who had vaginal births and 65% of women who had caesarean deliveries reporting that the labour and postnatal wards were crowded.

Differences in experiences of care were noted for several items between women who had vaginal births and those who had caesarean deliveries. Women who had caesarean deliveries reported greater privacy during examinations in the labour room. Just over half of women who had vaginal deliveries and a quarter of women who had caesarean deliveries reported that providers never introduced themselves. 86% of women who had vaginal births did not feel they could be in a position of their choice during delivery, and around one-third of women who had a vaginal delivery and half of women who had caesarean deliveries felt that providers always involved them in decisions about their care. Almost half of women who had vaginal births and a third of women who had caesarean deliveries said providers never asked permission before doing examinations or procedures on them. Similarly, almost half of women who had vaginal births and one-third of women who had caesarean deliveries felt they could not ask the doctors or nurses any questions. 28% of women who had vaginal deliveries and 10% of women who had caesarean deliveries felt providers did not do their best to control their pain.

Two additional questions were added to the survey for this rural SA sample related to whether women shared a bed and whether women would choose to give birth in the same facility again. Roughly 1 in 10 women reported that they had shared a bed with another woman at some time during their stay in the hospital. One in five women said if they had a choice they would definitely or probably choose not to give birth in the same facility again.

Mean PCMC scores on the full scale and subscales are shown in table 2 for all women and by mode of delivery. The mean total PCMC score was significantly higher for women who had caesarean deliveries compared with vaginal births (58.0 and 54.5, respectively). The mean score for the communication and autonomy subscale was also significantly higher among women who had caesarean deliveries. For the other two subscales, the average scores were also higher among women who had caesarean deliveries but the differences were not statistically significant.

To enable comparison across the domains, scores were rescaled (ie, shown as a fraction of the total possible score on that domain and normalised to 100) and shown in figure 1. The figure shows that the highest scores were obtained for the dignity and respect subscale at over 80% of the maximum possible score. The lowest performing area was communication and autonomy which was only 50% of the maximum possible score for women who had vaginal deliveries.

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Table 3 shows the mean PCMC score by selected predictors. Women aged 30–45 years had a higher mean PCMC score compared with women aged 16–19 years. Women in the middle, rich or richest quintiles had a higher mean PCMC score compared with the poorest women. Women who had eight or more antenatal visits, caesarean delivery, where the delivery provider was a doctor and those who delivered during the daytime had a higher mean PCMC score compared with women with less than eight antenatal visits, who had a vaginal delivery, where the delivery provider was a nurse or midwife and those who delivered during the night.

Accounting for the effect of all other predictors, attending eight or more antenatal visits and being in the middle wealth quintile was independently associated with a higher score on the total PCMC and all three subscales. For the other covariates, differences were noted across the subscales (table 4).

Having a caesarean delivery and being in the age group 30–45 years was associated with a higher total PCMC score while delivering during the night was associated with a lower total PCMC score adjusting for the effect of all other predictors. For the dignity and respect subscale, being in the age group 30–45 years and being in the middle or rich wealth quintile was associated with a higher score on this subscale while having three or more children was associated with a worse experience of care. For the communication and autonomy subscale, a higher score was associated with caesarean delivery, being in the age group 30–45 years, having tertiary education and being in either the middle or richest wealth quintile. Delivering during the night was associated with a lower score for the communication and autonomy subscale. For the supportive care subscale, giving birth during the night was associated with a lower score (table 4).

Discussion

Our results suggest that important areas for improvement exist within the South African maternity care context, in particular in relation to communication with women. Using a validated scale, we found a mean PCMC score of 55 (out of 90) with the domains of communication and autonomy and supportive care scoring lower than dignity and respect. The mean PCMC score for these rural districts in SA was lower than both the rural (59.5) and urban (60.2) samples in Kenya, higher than Ghana (46.5) and similar to India (55.8) where this tool has been previously applied.24

Areas of poor care that were common across all women irrespective of mode of delivery were fearing that their health information would not be kept confidential and having low levels of trust in their providers. Trust between women and providers has been described as a neglected yet important determinant of experiences of maternity care.34 We found that less than half of women reported that they could completely trust their provider all of the time. Lack of trust has major implications for women’s care-seeking and we found that one-fifth of our respondents would probably or definitely choose not to deliver at the same facility again if they had a choice which is severely limited in the public sector since it would require a long travel time to reach a different district hospital.

Women also reported a lack of basic infrastructure within health facilities such as a consistent supply of water and having to share a bed with another woman. The availability of water, sanitation and hygiene facilities in maternity units is essential for preventing infections. Our survey finding that less than half of women reported that there was water in the health facility all of the time they were there, is worse than the latest inspection report of the Office of Health Standards Compliance which found that 74% and 57% of health facilities in uMzinyathi and Zululand, respectively, were compliant with the required vital measures of maintenance of physical infrastructure and availability of back-up electricity and water supply.35 Research on obstetric disrespect and abuse has pointed to the stressors of under-resourced health systems in influencing health provider behaviours.36

The SA maternity care guidelines state that providers should ‘allow family and friends to provide companionship during labour’’,15 yet less than 15% of women reported being allowed to have a companion with them during labour or delivery. A labour companion can improve communication with health providers, articulate women’s concerns and provide practical help and support for women during labour. WHO recommends labour companionship as an intervention to improve respectful care, which has also been shown to improve maternal and perinatal outcomes.37 However, it is common for health workers to lack awareness about birth companions and express concern about overcrowding and privacy for other women in the labour ward, and this has hampered the implementation of birth companions in many settings,38 including in SA.

Experiences of physical abuse by women in our sample were relatively few (7%) which may indicate a shift from what has been reported from previous qualitative research in SA.8 However, verbal abuse remains common with around 20% of women, irrespective of the mode of delivery, reporting verbal abuse at least once. These rates are similar to what was found from the same survey tool applied in urban Kenya and India but higher than rates reported by women in rural Kenya and Ghana.24

Women who had caesarean births reported significantly better experiences of care compared with women who had vaginal births although these experiences were still far below acceptable quality of care. This is the first time experience of care among women who have had caesarean delivery has been measured in SA; however, a similar finding was reported from a study using the PCMC tool in Rural Kenya, Ghana and India39 and from a facility and community survey in Tanzania.40 The main areas where experiences of care were better for women who had caesarean deliveries were privacy during examinations, communication (providers introducing themselves, involving women in decisions, asking permission for examinations) feeling able to ask questions of providers and experiencing better control of pain. Women who had vaginal deliveries did not differ from women who had caesarean deliveries for any sociodemographic characteristics but there were important differences in type of health provider (doctor compared with midwives/nurses) provider gender (more males conducted caesarean deliveries) and timing of delivery (more caesarean deliveries occurring in the daytime). Provider interactions with women may differ when a complication or risk is identified which may partially explain the perception of better communication from women who had caesarean deliveries. Women who have caesarean deliveries have to go through a consent procedure with a health professional and may have experienced complications in labour and perceive the procedure to have been life-saving for themselves or their infants. Furthermore, they also stay longer in the hospital and therefore encounter a range of providers in labour and postnatal units all of which may influence their overall perception of communication and their sense of autonomy.

Besides the mode of delivery, we found several other factors independently associated with better experiences of care including older age, attending more antenatal visits, delivering during the daytime and a higher socioeconomic status. A cross-sectional facility-based survey in Ethiopia also reported better experiences of RMC among women who delivered during the daytime.41 Night shifts typically have less management supervision and providers may suffer from exhaustion particularly if they have household and family responsibilities that prevent them from resting during the day when they are off shift. In SA, studies have found a high level of personal and work-related burnout and stress among health workers,42–44 which may provide some context for the lack of empathy displayed by some health workers.

Our findings complement previously conducted qualitative research in SA describing women’s experiences of care in childbirth.8 10 13 While the qualitative research has described both verbal and physical abuse, our survey found that reports of physical and verbal abuse were relatively uncommon but the different methodologies used prevents us from concluding whether this represents an improvement.45

The findings from this baseline survey point to important gaps that will be the focus of the next phase of this research, which aims to develop a participatory intervention to improve RMC within rural maternity teams. Despite the well-documented manifestations and structural drivers of mistreatment and a supportive policy environment in SA, very little attention has been paid to how to operationalise RMC46 among multidisciplinary teams of health workers in public sector maternity units; specifically how to change organisational cultures that normalise disrespect and abuse.36 Previous research in SA has focused on promoting birth companions through an educational package provided to maternity staff but found no impact of the intervention after 8 months. Challenges identified included the lack of team consensus to implement change, high staff turnover and lack of support from hospital management.47 The existing global evidence synthesis suggests that multicomponent48 and continuous education involving multidisciplinary teams49 rather than once-off interventions would help promote respectful care.

Conclusion

SA has made great strides in revising policies and guidelines to prioritise RMC yet this research found that women attending rural health facilities experienced disrespect, lack of support and trust in an environment where they had little involvement in decisions about their care and felt unable to ask questions of their providers. These findings support the need for interventions48 addressing infrastructural deficiencies and organisational cultures that allow disrespect within maternity units. In addition, particular aspects of care that require attention include fostering trust with providers and respectful communication, particularly for women having a vaginal delivery, as well as openness to companionship in labour and delivery. Importantly, interventions to improve respectful care should include maternity staff working night shifts.