Table 4.

Magnitude, strengths, and areas of improvement across each domain of HSR for universal maternal healthcare services in East Africa

Domains	Magnitude	Strengths	Areas of improvement
Autonomy	Women’s autonomy for maternity care: 57.9–66.8% [17, 24, 25].	Obtaining consent of women before doing any procedures and examinations [33–35]. Respecting women’s right to choice of care provider and refusal to care [36]. Involving women in decision-making and sharing information [34, 37, 38].	Conduct physical assessments and procedures without explaining the procedure in non-emergency situations [26–29]. Undermined women’s decision-making power and right to refuse unfavourable conditions [28]. Low involvement of woman in decision-making during caesarean delivery [29, 30]. Unable to involve women in the decision of delivery position, having companions during labour, and procedures [10, 31, 32].
Confidentiality	Confidentiality of maternity care: 15–89.3% [17, 24, 25, 39–45]. Other studies reported non-confidential maternity care: 35–66.2% [46–51].	Midwives never share women’s information with non-concerned individuals [52].	Violating the privacy of information during maternity care [27, 36, 43, 53–59]. Sharing a single room by two or more women [36, 53, 56, 58, 59]. Absence of screens or partitions between delivery couches [54, 55].
Dignity	Dignified maternity care: 70.8–80% [17, 24, 25, 39, 44, 53]. Other studies reported non-dignified maternity care: 25.5–60.4% [46–50, 60].	Initiation of non-discriminatory care [35]. Respecting the right to equality and equitable care, the right to liberty and freedom from coercion [36]. Practicing abuse-free care [33, 69]. Covering the maternal perineum and maintaining privacy during care [37, 61].	Physical abuse, including beating, slapping, pinching, physical assault, and forceful opening of women’s legs [27, 28, 36, 61–65]. Lack of privacy during childbirth and physical assessments caused humiliating and disappointing, causing anxiety, additional pain, and discomfort to women [10, 28, 32, 57, 59, 63, 66–69]. Verbal abuse, including shouting, insulting, yelling, verbal harassment, unpleasant language, lack of compassion, and blaming [10, 26–28, 31, 32, 36, 39, 52, 59, 61–66, 69–72]. Providers perception on slapping or pinching, holding a woman forcefully on a delivery bed, and verbally threatening were acceptable to avoid adverse birth outcomes [33, 59, 70]. Declined women’s health services [25, 72]. Unfriendly maternity care [31, 68, 73]. Unfair healthcare service provision and stereotyping practices [10, 27, 59, 71]. Lack of sympathy, lack of hospitality, poor receptiveness, neglected care, and negative attitudes of healthcare providers [10, 28, 64, 74, 75].
Basic amenities	Quality of basic amenities: 45.8–65.8% [17, 24, 25].	Use of sterile equipment and clean bed linen [29, 37, 67]. Healthcare facilities keep their compound clean and gave sufficient food to women [29, 62].	Poor hygiene of delivery beds or rooms, dirty washrooms, unhygienic health facilities, and unhygienic practices of healthcare workers and support staff [10, 28, 62, 63, 67, 71, 77]. Poor infection prevention protocols, poor room arrangements, and non-favourable working environments [29, 68, 75]. Lack of water, inadequate feminine hygiene products, cotton wool, sanitary pads, sheets, detergents, and unstable electric sources with no backup [10, 25, 28, 54, 62, 77, 78]. Inadequate and poor food quality [63, 77]. • Lack of enough bed and bed sheets, blankets, shower rooms, personal protective equipment, delivery coaches, bedpan, and waiting rooms [32, 39, 75, 78]. Lack of a maternity-specific operating theatre for caesarean Sect. [58].
Choice of care providers	Choice of healthcare provider: 41.6–68% [17, 24, 25].		Women’s provider preferences were not maintained [10, 25, 38, 56, 66, 78, 79]. Concern of women by male healthcare provider [10, 56, 66, 79]. Lack of experience, expertise, and attitudes of providers [72]. Frequent changes in service providers, particularly during ANC visits [75]. Disruptions in service operations, loss of trained staff, increased staff fatigue and workloads, and negligence in care [31, 62, 64, 68, 75, 78]. Poor health workers’ discipline and readiness [68, 71]. Weak provider and women relationships [65]. Unable to employ specialists and other healthcare workers [63]. Absence of supervision by senior healthcare professionals [68]. Undergoing frequent examinations [69]. Lack of supervision [28].
Communication	Effective communication: 46–76.3% [17, 24, 25, 43, 53, 73, 80].	Friendly welcome with polite language, introducing themselves, calling clients by name, positive non-verbal body gestures, and establishing an interpersonal connection [32, 34, 35, 37, 61, 62, 67]. Care providers provided their phone numbers for continuous communication [52, 71]. Trust between care providers and women [65, 84, 85]. Making women feel well before care, receiving care from the same care provider, and calling women by name [32, 34, 38, 65].	Communication gaps or inadequate information [25–27, 29, 31, 52, 53, 63, 67, 81]. Poor care provider-client relationships and the use of medical jargon words or other non-local languages during discussion [10, 26, 31, 65]. Allowed only a one-way hierarchical communication [62]. Unnecessary referrals, poor referral linkages or communication between different levels, and lack of midwives’ decision-making power on referrals [78, 82]. Misinformation, poor interaction, fearful news about COVID-19, and providers’ rude and abusive speech [56, 58, 65, 74, 83].
Prompt Attention	Prompt attention (timely) maternity care: 62.1–96.3% [17, 24, 25, 42, 45, 76, 86–89].	Timely care provision, availability and readiness of healthcare workers [37, 62, 69].	Far geographical distance from healthcare facilities [66, 71, 77, 90]. Long wait times for care and delays in receiving care [10, 29, 36, 39, 43, 56, 62, 63, 66, 68, 71, 73, 75, 90, 91]. Lack of staff and high workload [29, 36, 39, 90]. Closure of healthcare facilities during the night, unreasonable delays, providers’ absenteeism or late entrance from work, and lack of equipment and supplies [56, 66, 75]. Non-accessible roads, challenging topography, lack of transportation options, and inadequate number of ambulances [56, 64, 66, 71, 73, 83, 90]. Transportation bans or lockdowns, especially during emergencies like pandemics [83].
Social support	Women allowed social support or companionship during maternity care: 13.8–69% [17, 24, 25, 55, 76, 86, 92]	Respect the right to have a birthing companion [33]. Involving companions enhancing confidence in difficult situations, providing emotional support, facilitating referrals and continuity of care, persuading uncooperative women, and linking the midwife’s instructions with the woman’s adherence [28, 34, 35, 55, 93]. Birth companions identify complications, inform medical staff, and bring essential supplies [28].	Women did not have companions, which made their stay at health facilities unfavourable [10, 26, 28, 37, 53, 55, 81, 83]. Providers not allowed companions because of fear of witnesses during incidents and unsupportive administration [55]. Worsening of the coronavirus during the pandemic periods [81]. Cultural preferences incompatible with health facility practices [66]. Absence of celebration after childbirth at health facilities [64].