Factors associated with respectful maternity care and influence of HIV status among women giving birth in Kilimanjaro, Tanzania

Abstract

Background:

Respectful maternity care (RMC) is a rights-based approach to childbirth that centers the dignity, autonomy, and well-being of the birthing patient. This study aimed to examine factors associated with RMC among women giving birth in Tanzania, and to examine whether HIV status was associated with self-reported RMC.

Methods:

We enrolled 229 postpartum women in six clinics in the Kilimanjaro Region, of them 103 were living with HIV. Participants completed a survey within 48 hours after birth, prior to being discharged. RMC was measured using a 30-item scale with three subscales (dignity and respect; supportive care; communication and autonomy), each standardized from 0–100. Univariable and multivariable regression models examined factors associated with RMC.

Results:

The median score of the full RMC score was 74, differing slightly by subscale: 83 for dignity and respect, 76 for supportive care, and 67 for communication and autonomy. RMC did not differ by HIV status (median 67.0 vs. 67.0, p=0.89). In multivariable linear regression, women who would not recommend the birth facility to their friends and who did not receive breastfeeding education had significantly lower RMC scores on the full RMC scale. In the dignity and respect subscale, variables associated with significantly lower RMC scores were not being able to read and write, delivering in a public facility, and delivering vaginally.

Conclusions:

Although self-reported RMC was generally high, we identified areas for improvement. Providers need ongoing training on RMC principles and on the delivery of equitable care.

INTRODUCTION

Respectful Maternity Care (RMC) is centered on improving the interpersonal interactions between a woman and her healthcare providers throughout the perinatal continuum.¹ RMC focuses on eliminating ill and abusive behavior by healthcare providers and associated staff, and on promoting a sensitive and encouraging care environment to make a woman feel safe and respected during childbirth.¹ The provision of RMC ensures quality maternal and newborn care and ultimately impacts women’s decision to use facility-based services for future births.² Data from healthcare facilities around the world report that childbirth is often accompanied by disrespect and abuse, which not only undermines women’s dignity, but also contributes to poor maternal and child health outcomes.^3–5

Mistreatment of women during facility-based delivery is both a public health and a human rights challenge. Mistreatment predisposes women to emotional distress, decreases rates of in-facility delivery, and often leads to poor clinical outcomes.⁶ Addressing maternal, neonatal, and under-five mortality has been a major target for the World Health Organization (WHO) and has been central on both the Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs).^7,8 RMC contributes to these targets by increasing the proportion of facility-level births and improving the quality of care, thus addressing both maternal and child morbidity and mortality.^2,9,10 Efforts to improve maternal health via respectful maternity practices are consistent with SDG 3 (targets 3.1 and 3.2), which highlights the need to reduce global maternal and neonatal mortality, and SDG 5, which focuses on gender equality.⁷ These targets build on MDG 4 and 5, which aim to reduce the mortality rates of youth under five by two-thirds and of mothers by three-quarters by 2015. It has been over two decades since the MDGs were established, yet Sub-Saharan Africa remains behind in reaching these goals, with one million newborn deaths and stillbirths every year.¹¹ It is estimated that about half of all newborn deaths and stillbirths in low and middle-income countries (LMICs) are intrapartum related, which is much higher than in high-income settings.^12,13 Improving both maternal and newborn outcomes requires improving the practices of RMC during labor and delivery (L&D) in health facilities.¹⁴

In a study conducted in Ghana, Guinea, Myanmar, and Nigeria, more than 40% of observed women and 35% of surveyed women experienced disrespect and abuse (D&A) during childbirth, ranging from a lack of respectful care to overtly abusive acts in healthcare facilities.¹⁵ Evidence shows that negative childbirth experiences are more common in LMICs compared with higher-income countries.¹⁶ Mistreatment during childbirth has been associated with overcrowded L&D wards and a lack of adequate staff, leading to overburdened lower-level providers.¹⁶ Many urban hospitals have an extremely high patient load, yet are faced with significant resource and staff shortages, which is likely one of the key drivers of D&A.^17–19 Several studies have described D&A among women giving birth in Tanzania.²⁰ In the Mara and Kagera regions of Tanzania, a cross-sectional household survey of 732 women giving birth at a health facility found that 73.1% of women reported D&A during childbirth.²¹ In Dar es Salaam, 15% of women reported D&A during facility-based childbirth.¹⁹

Women living with HIV (WLHIV) may experience a lower quality of care during childbirth due to negative attitudes about people living with HIV, inadequate knowledge of HIV management, and health workers’ fear of HIV infection.²² HIV-related stigma and discrimination during childbirth can create barriers to the use of essential maternal and HIV health services, leading women to have suboptimal engagement in HIV care or to drop out of care altogether.^23,24 In the postpartum period, antiretroviral therapy adherence is impacted by anticipated stigma from communities and healthcare facilities.²⁵ Anticipated stigma can lead women to hide their HIV status from partners and family members, to avoid attending HIV clinical care, and to have suboptimal adherence to both their own HIV medication and HIV prophylaxis medication for their newborns.^26,27 Respectful maternity care during the intrapartum period has the potential to reduce HIV stigma and prepare women to engage in HIV care postpartum.²⁸

In Tanzania, RMC has been identified as a national priority, and in 2019 was integrated into the Tanzanian health sector policy and service delivery guidelines.²⁹ The goal of this paper is to describe RMC in a sample of women giving birth in the Kilimanjaro Region, and to examine factors associated with RMC, including HIV status.

METHODS

This study used the baseline data from a population of birthing individuals who were assessed as part of the evaluation of a simulation training intervention for L&D providers (NCT05271903). All data were collected between March and July 2022.

Study setting and participants.

Study sites included six health facilities across two districts in the Kilimanjaro Region: Moshi (urban) and Rombo (rural). The Tanzanian healthcare system is decentralized and organized in a referral pyramid (primary, secondary, and tertiary levels), and deliveries occur at all healthcare facility levels. For our study, we selected one district hospital and two health centers from each district, all of which are considered primary healthcare centers.³⁰ The two district hospitals are private, faith-based facilities, and the remaining health centers are public facilities. Caesarean births are performed in the two district hospitals and two health centers (one in each district). The remaining two health centers must refer patients to another center or district hospital if they require a caesarean birth.

Women who gave birth in any of the six study clinics during the data collection period were eligible to participate. We excluded individuals who had mental or physical disabilities (e.g., difficulty seeing or hearing) that limited their ability to provide consent. In order to have sufficient data on the influence of HIV status on RMC, we purposively sampled all WLHIV in the study facilities during the recruitment period. If a WLHIV gave birth, L&D staff informed the patient about the study and asked if she was interested in participating. If she was, the study team was notified through a phone call or text message. A member of the study team would then travel to the clinic to meet with the patient in the postpartum ward after birth, prior to discharge. For each WLHIV who was enrolled in the study, we recruited one or two HIV-negative women who gave birth in the study facility at the same time. We used the following criteria in selecting HIV-negative participants in relation to the index WLHIV: similar date and time of childbirth, similar parity (primiparas or multiparas), same mode of delivery (caesarean or vaginal birth), and similar age (+/− 3 years). The purpose of the matching criteria was to ensure that the two samples (WLHIV and HIV-negative women) were balanced across key variables.

Study procedures

After confirming that the patient met the study eligibility criteria, the study staff orally administered informed consent and provided time to answer any questions. After consent, the participant was then issued a unique study ID, which was attached to all participant data. Participants completed a structured survey in Swahili on a touchscreen tablet using audio computer-assisted self-interview (ACASI) technology via the Questionnaire Development System (QDS) software. The ACASI process ensures participant privacy and reduces social bias, thus improving data validity.³¹ A member of the study team helped participants to understand how the ACASI worked and completed the demographics questions with them. Participants were then left to listen to the audio-recorded questions and indicate their responses using the touch screen. The study team member was available for any questions. The survey took about 30–45 minutes to complete. A member of the study team gathered relevant data from the patient’s medical record using a structured form. The form included information pertaining to the patient’s medical history, clinical management, complications, and birth outcomes.

Outcomes

The primary study outcome was self-reported perceptions of RMC. We used a Swahili version of the validated Person-Centered Maternity Care (PCMC) scale, developed by Afulani and colleagues to measure women’s experiences of RMC during labor and delivery.^32–35 The PCMC measure uses a Likert scale to rate RMC across 30 items, with higher scores corresponding to higher levels of RMC. Questions spanned three domains: dignity and respect (6 items), communication and autonomy (9 items), and supportive care (15 items). Summed measures were created and standardized from 0 to 100 for the full RMC score (α=0.81), and for the three domains: dignity and respect (α=0.71), communication and autonomy (α=0.61), and supportive care (α=0.57).

Covariates

The survey included demographic questions about age, education, marital status, literacy, religion, and household wealth. Household wealth was measured in quintiles and calculated from the wealth index based on 10 questions about household assets.³⁶ We used the medical record data to record parity (categorized as first birth vs. previous birth) and number of antenatal care (ANC) visits (categorized as <4 vs. ≥4) for birth history.

Information extracted from the medical record included the type of facility (public/private) and mode of delivery (vaginal/caesarean birth). We also recorded any complications during labor, birth and postpartum periods, including postpartum hemorrhage (500 mls or more of bleeding after birth), preeclampsia (pregnancy with high blood pressure and protein in urine), and obstructed labor (failure to progress in labor).

Participants’ self-reported information also included: gender of primary provider (male/female); breastfeeding education/support; and likelihood to recommend the facility to a family or friend for a future birth. The participant’s HIV status was communicated to the study staff when they were notified of a possible new study participant. This information was confirmed by checking the HIV status on the participant’s medical record.

Sample size

We aimed to recruit a minimum of 206 participants (103 WLHIV and 103 HIV-negative women). The estimated sample size aimed to detect a moderate effect (d=0.4) on RMC scores, comparing WLHIV and HIV-negative women with α = 0.05 and a power of 80%. The sample size calculations were performed using the G*Power software.

Data processing and analysis

We merged participant data (collected by ACASI) and medical record data (entered into REDCap software). Merged data were exported to Statistical Package for Social Science (SPSS) software v.25 for data cleaning and analysis. First, the characteristics of the participants were described by summary statistics. For categorical variables, frequency and percentages were used. For continuous variables, means (standard deviation) or medians (interquartile ranges) were used. We compared the characteristics of WLHIV and women without HIV using a t-test for continuous variables and a chi-square test for categorical variables. Regression coefficients and their corresponding 95% confidence intervals for the factors associated with RMC were estimated using a linear regression model. Covariates that had p<0.1 in univariable analysis were included in the final multivariable analysis. Demographic predictor variables (age, marital status, literacy, wealth, and religion) were selected a-priori to be included in the final multivariable models, regardless of significance in univariate analysis.

RESULTS

Study participants

The study enrolled 229 women, including 103 WLHIV, who had recently given birth. Participants’ characteristics are described in Table 1. Participants had a median (Q1, Q3) age of 27 years (23, 31). Compared with HIV-negative women, WLHIV were more likely to have only a primary level of education (53.7% vs. 46.3%; p<.05), to be unable to read and write (26.2% vs. 12.7%; p<.01), to have received breastfeeding education (74.8% vs. 62.4%; p<.05), and to not recommend the labor and delivery facility to their friends for future births (8.7% vs. 2.4%; p<.05).

Table 1:

Characteristics of study participants (n=229)

Variable	Full Sample (n=229)	HIV Negative (n=126)	WLHIV (n=103)	p-value *
	n (%) a	n (%)	n (%)
Age (Median [Q1, Q3])	27 (23, 31)	26 (22,29)	29 (25,33)	0.001
Education level
Primary or lower	108 (47.2)	50 (46.3)	58 (53.7)	0.012
More than primary	121 (52.8)	76 (62.8)	45 (37.2)
Marital status
Not married	88 (38.6)	43 (34.1)	45 (44.1)	0.123
Married	140 (61.4)	83 (65.9)	57 (55.9)
Literacy: reading & writing
No, cannot read or write well	43 (18.8)	16 (12.7)	27 (26.2)	0.009
Yes, can read and write well	186 (81.2)	110 (87.3)	76 (73.8)
Wealth quintile
Lowest or middle quintile	45 (19.8)	21 (16.8)	24 (23.5)	0.206
Highest quintile	182 (80.2)	104 (83.2)	78 (76.5)
Religion
Christian	171 (74.7)	91 (72.2)	80 (77.7)	0.346
Muslim and other	58 (25.3)	35 (27.8)	23 (22.3)
Parity
Primipara	63 (27.5)	34 (27.0)	29 (28.2)	0.843
Multipara	166 (72.5)	92 (73.0)	74 (71.8)
Number of ANC visits
< 4	55 (24.4)	30 (24.2)	25 (24.8)	0.923
≥ 4	170 (75.6)	94 (75.8)	76 (75.2)
Type of healthcare facility
Public	160 (69.9)	86 (68.3)	74 (71.8)	0.556
Private	69 (30.1)	40 (31.7)	29 (28.2)
Birth type
Vaginal	177 (77.3)	102 (81.0)	76 (73.8)	0.195
Cesarean section	52 (22.7)	24 (19.0)	27 (26.2)
Gender of provider
Male	106 (46.3)	53 (42.1)	53 (51.5)	0.156
Female	123 (53.7)	73 (57.9)	50 (48.5)
Complications during labor/birth/postpartum
No	117 (51.1)	70 (55.6)	47 (45.6)	0.135
Yes	112 (48.9)	56 (44.4)	56 (54.4)
Breastfeeding education/support
No	73 (32.0)	47 (37.6)	26 (25.2)	0.047
Yes	155 (68.0)	77 (62.4)	78 (74.8)
Facility recommended to the friends for labor & delivery
No	12 (5.2)	3 (2.4)	9 (8.7)	0.032
Yes	217 (4.8)	123 (97.6)	94 (91.3)

^*p-value derived from t-test and chi-square

^aSummation may not add to the total due to missing values.

Comparison of RMC full scale and subscales

Overall reports of RMC were high (Figure 1). The median (IQR) score of the full RMC scale was 74.4 (64.2, 83.3). Considering the three RMC subscales, scores were highest in dignity and respect (83.3; IQR 66.7, 94.4), followed by supportive care (75.6; IQR 68.3, 84.4), and then communication and autonomy (66.7; IQR 51.9, 77.8).

Figure 1:

Comparison of RMC full and subscales (n=229)

Factors associated with RMC during childbirth.

Tables 2 and 3 show the results of the regression models predicting RMC scores. The final multivariable analysis revealed several factors that were significantly associated with the full RMC score and/or the sub-scale scores. Women who were not able to read and write (ß = −1.1; 95%CI: −2.1, −0.04), delivered in the public facilities (ß = −1.3; 95%CI: −2.2, −0.4), and delivered vaginally (ß = −1.2; 95%CI: −2.1, −0.3) had significantly lower scores in the dignity and respect subscale. Women who said they would not recommend the facility to their friends for future births had significantly lower scores in the full RMC scale (ß = −14.3; 95%CI: −20.3, −8.3), the dignity and respect subscale (ß = −4.4; 95%CI: −6.0, −2.7), the communication and autonomy subscale (ß = −4.3; 95%CI; −6.9, −0.7) and the supportive care subscale (ß = −14.3; 95%CI: −20.3, −8.3). Women who reported that they did not receive breastfeeding education had significantly lower scores in the full RMC scale (ß = −4.7; 95%CI: −7.5, −1.8), dignity and respect subscale (ß = −1.5; 95%CI: −2.3, −0.7), and supportive care subscale (ß = −4.7; 95%CI: −7.5, −1.8). There was no difference in RMC scores by HIV status (Table 2 and 3).

Table 2:

Factors associated with the full RMC scale (n=229)

Variable	Univariate analysis		Multivariate analysis
	Unadjusted regression Coefficient (95% CI)	p-value	Adjusted regression Coefficient (95% CI)	p-value
DEMOGRAPHICS
Age	0.01 (−0.2, 0.3)	0.906	−0.1 (−0.3, 0.2)	0.666
Education level
Primary or lower	1
More than primary	0.6 (−2.3, 3.5)	0.699
Marital status
Not married	−2.4 (−5.4, 0.5)	0.107	2.4 (−0.4, 5.2)	0.243
Married	1
Literacy: reading & writing
No, cannot read or write well	−4.5 (−8.1, −0.8)	0.017	−2.4 (−5.8, 1.5)	0.243
Yes, can read and write well	1
Wealth quintile
Lowest or middle quintile	−3.6 (−7.2, −0.04)	0.048	−1.1 (−4.6, 2.5)	0.544
Highest quintile	1
Religion
Christian	0.3 (−2.9, 3.7)	0.831	−0.6 (−3.7, 2.6)	0.713
Muslim/others	1
BIRTH HISTORY
Parity
Primipara	−1.3 (−4.5, 2.0)	0.439
Multipara	1
Number of ANC visits
< 4	1
≥ 4	1.0 (−4.4, 2.4)	0.560
CONTEXT OF BIRTH
Type of healthcare facility
Public	−3.5 (−6.6, −0.4)	0.026	−2.8 (−5.9, 0.2)	0.068
Private	1
Birth type
Vaginal	−1.9 (−5.4, 1.5)	0.266
Cesarian section	1
Gender of provider
Male	1.6 (−1.3, 4.5)	0.278
Female	1
Complications during labor/birth/postpartum
No	−0.5 (−3.3, 2.7)	0.758
Yes	1
Breastfeeding education
No	−4.5 (−7.5, −1.4)	0.004	−4.7 (−7.5, −1.8)	0.002
Yes	1
Facility recommendation
No	−14.7 (−20.9, −8.5)	<0.001	−14.3 (−20.3, −8.3)	<0.001
Yes	1
HIV
HIV status
Negative	1
Positive	−1.0 (−3.9, 1.9)	0.489

Table 3:

Factors associated with the RMC sub-scales (n=229)

Variable	Dignity and respect		Communication and Autonomy		Supportive care
	Univariate analysis	Multivariate analysis	Univariate analysis	Multivariate analysis	Univariate analysis	Multivariate analysis
	Unadjusted regression Coefficient (95% CI)	Adjusted regression Coefficient. (95% CI)	Unadjusted regression Coefficient (95% CI)	Adjusted regression Coefficient. (95% CI)	Unadjusted regression Coefficient (95% CI)	Adjusted regression Coefficient. (95% CI)
DEMOGRAPHICS
Age	0.07 (−0.04, 0.1)	0.02 (−0.1, 0.1)	−0.1 (−0.2, 0.1)	−0.1 (−0.2, 0.1)	0.02 (−0.1, 0.2)	−0.1 (−0.2, 0.1)
Education level
Primary or lower	1		1		1
More than primary	0.3 (−0.6, 1.1)		0.2 (−1.0, 1.4)		0.01 (−1.4, 1.4)
Marital status
Not married	−0.8 (−1.6, 0.1)	0.7 (−0.1, 1.5)	−0.7 (−1.9, 0.5)	0.9 (−0.3, 2.2)	−1.0 (−2.4, 0.4)	0.7 (−0.7, 2.1)
Married	1		1		1	1
Literacy: reading & writing
No, cannot read or write well	−1.8 (−2.8, −0.7) **	−1.1 (−2.1, −0.04) *	−1.3 (−2.8, 0.3)	−0.4 (−2.0, 1.2)	−1.3 (−3.1, 0.5)	−0.9 (−2.7, 1.0)
Yes, can read and write well	1		1		1	1
Wealth quintile
Lowest or middle quintile	−1.3 (−2.3, −0.2) *	−0.2 (−1.2, 0.8)	−1.7 (−3.2, −0.2) *	−1.0 (−2.5, 0.6)	−0.7 (−2.4, 1.1)	0.2 (−1.5, 1.9)
Highest quintile	1		1		1	1
Religion
Christian	0.9 (−0.3, 1.7)	0.3 (−0.5, 1.2)	0.2 (−1.2, 1.6)	0.1 (−1.3, 1.5)	−0.5 (−2.1, 1.1)	−0.5 (−2.0, 1.1)
Muslim/others	1		1		1	1
BIRTH HISTORY
Parity
Primipara	0.1 (−0.8, 1.0)				−1.7 (−3.2, −0.2) *	−1.8 (−3.6, 0.1)
Multipara	1				1	1
Number of ANC visits
< 4	−0.3 (−1.3, 0.7)				1
≥ 4	1				0.03 (−1.6, 1.7)
CONTEXT OF BIRTH
Type of healthcare facility
Public	−1.7 (−2.6, −0.9) **	−1.3 (−2.1, −0.4) **	−0.9 (−2.2, 0.4)		−1.0 (−2.4, 0.6)
Private	1		1		1
Birth type
Vaginal	−1.4 (−2.4, −0.4) **	−1.2 (−2.1, −0.3) *	−1.4 (−2.8, 0.01)	−1.3 (−2.7, 0.1)	0.9 (−0.8, 2.5)
Cesarian section	1		1		1
Gender of provider
Male	0.6 (−0.2, 1.5)		0.9 (−0.3, 2.1)		0.1 (−1.3, 1.5)
Female	1		1		1
Complications during labor/birth/postpartum
No	−0.4 (−1.3, 0.4)		−1.0 (−2.2, 0.2)		1.0 (−0.4, 2.3)
Yes	1		1		1
Breastfeeding education
No	−1.5 (−2.4, −0.6) **	−1.5 (−2.3, −0.7) ***	−0.9 (−2.2, 0.3)		−2.1 (−3.5, −0.6) **	−2.1 (−3.5, −0.7) **
Yes	1		1		1	1
Facility recommendation
No	−4.4 (−6.2, −2.7) ***	−4.4 (−6.0, −2.7) ***	−4.3 (−6.9, −1.7) **	−4.0 (−6.6, −1.3) **	−6.0 (−9.0, −3.0) ***	−5.8 (−8.8, −2.8) ***
Yes	1				1	1
HIV
HIV status
Negative	1		1		1
Positive	−0.2 (−1.0, 0.7)		0.1 (−1.1, 1.3)		−1.0 (−2.3, 0.5)

^*p< 0.05

^**p<0.01

^***p<0.001

DISCUSSION

The overall report of RMC in this study was relatively high with a median score of 74 on the full RMC scale. This was higher than seen in previous studies conducted in Ghana ³² and Northeastern Ethiopia, ³⁷ which reported scores of 50 and 64, respectively. The difference with our study might be due to variations in methodology, health policy and study settings. This study did not identify a difference in RMC comparing women living with and without HIV. This echoes previous findings from Sando et al.²³

The dignity and respect subscale had the highest median score, followed by supportive care, then communication and autonomy. This ranking of sub-scale scores was similar to the other studies.^32,38 The high levels of self-reported RMC in this population of postpartum women are encouraging and reflect patient satisfaction with birthing services at the study facilities. The lower score on communication and autonomy points to a need for additional provider training in clinical empathy and consent to center women’s autonomy and well-being in the labor and birth experience.

Women with low socioeconomic status (indicated by low literacy or income levels) were significantly more likely to report lower RMC scores. Studies have consistently shown provider bias toward women from low socioeconomic backgrounds. ^39–41 In Tanzania, birthing women are often expected to bring their own delivery supplies to the clinic (e.g., cotton gauze, a plastic cover to deliver on, gloves, clean clothes for both mother and baby (khangas/vitenge), and money in case of any emergencies), and women who are not able to do so are likely to receive suboptimal care.⁴² Bias toward birthing women from low socioeconomic backgrounds further reinforces health disparities, and may discourage these women from seeking facility-based births.

Women who delivered in public health facilities reported lower RMC scores. This may be explained in part by challenges including provider overload and burnout in the public sector.^{35,37,43–45} Shortages in human resources for healthcare can significantly impact the quality of care provided and can undermine the rapport built between providers and their patients.^43,45 A low RMC score was also significantly associated with an unwillingness to recommend the facility to other birthing women, suggesting that poor treatment during childbirth may lead women to choose future births in other facilities or outside the medical system altogether.

RMC in our sample did not differ by HIV status, which is consistent with previous research that showed no difference in D&A by HIV status ⁴⁶. This may be evidence of the increasing normalization of HIV in the Tanzanian clinical setting, and providers’ self-efficacy to safely care for WLHIV. It is worth noting, however, that WLHIV were significantly less likely to say they would recommend the L&D facility to their friends for future birthing (Table 1), which indicates some greater likelihood of WLHIV being dissatisfied with care.

The challenges we identified suggest a need for additional training on RMC. Manu et al., found in 2021 that 25% of L&D providers in the Njombe District of Tanzania had never received training on RMC,⁴⁷ even though RMC was identified as a national priority to be integrated into health sector policy and service delivery guidelines in 2019.²⁹ Interventions such as simulation that focus on training clinical providers to deliver evidence-based and respectful maternity care to all women are important to optimize outcomes among birthing women.

This study had several key strengths, including the inclusion of both private and public facilities across rural and urban settings and the use of a robust self-reported measure of RMC that had been validated in an East African setting.^32,35 Use of ACASI enabled participants to freely express themselves and enhanced privacy.³¹ However, the study has limitations that must be considered in interpreting the results. Most notably, a self-reported measure of RMC is subject to recall bias, which may be clouded by the outcome of the pregnancy. Since the interview was conducted within 48 hours post-delivery, a positive delivery outcome may increase the likelihood of a high RMC rating. In our study, all but one woman gave birth to live healthy babies. In addition, since the study was conducted at the health facility, there was a possibility of social desirability bias, as women may not have felt comfortable offering critical opinions about the care they received at the clinic while still there. To minimize this, ACASI was used, and participants were assured from the beginning that their personal details would not be disclosed to the hospital staff or anyone else. We also understand that the level of education and cadre of the birth attendants can impact the practices of RMC, but it was not possible to obtain this information from the participants or medical record forms. Finally, high self-reported RMC may sometimes reflect low expectations for care as has been indicated in the literature.⁴⁸ This may be the case particularly for WLHIV, who may have even lower expectations of care given their anticipated stigma. A study by Smith and colleagues in Zambia reported that women’s primary concern during labor and delivery was to have a healthy baby, which may lead them to minimize abusive behaviors.⁴⁸ As patients become more aware of their rights and develop higher expectations for the care received during birth, it is possible that self-reported RMC may decrease, even as the quality of care improves.

CONCLUSION

The high levels of self-reported RMC in this population of postpartum women are encouraging and reflect that women are generally satisfied with the birthing services provided in the study facilities. Importantly, there is still room for improvement, as the ultimate goal is to achieve full RMC in all domains, with most progress needed in the area of communication and autonomy. There are opportunities to increase the amount of training healthcare providers receive on key skills such as clinical empathy and informed consent. To optimize outcomes for both birthing women and newborns, attention should be given to improving the quality of care through ongoing training and support of clinical providers to deliver evidence-based, respectful care to all women, regardless of their personal background.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon request.