Midwives practices and mothers’ experiences during intrapartum midwifery care: a qualitative study

Abstract

Background

Limited research addresses the intersection of women's intrapartum care experiences and midwives' daily practices within the same facilities, resulting in insufficient documentation of discrepancies between expectations and care routines. For women with low-risk pregnancies, midwife-led care is optimal. Quality intrapartum care measures are essential for reducing avoidable maternal-newborn morbidity and mortality. One factor contributing to the high rate of maternal and neonatal morbidity is sub-standard care. Thus, this study aimed to understand midwives’ practices and mothers’ experiences during intrapartum care.

Methods

This exploratory qualitative descriptive study was conducted in three health facilities in South Western Uganda between April 2025 and May 2025. Eleven (11) mothers admitted in early labour, expecting a normal physiological birth, and receiving midwifery care were purposively selected. Through nonparticipant direct observation ten (10) midwives were observed while caring for mothers in labour and in-depth interviews were conducted with the mothers after receiving care. Latent content analysis was applied for direct observations data, thematic analysis was applied for in-depth interviews data finally both data sets were triangulated.

Results

Three main themes emerged: “Disrespectful and Abusive intrapartum care” This emerged from three sub themes: Mistreatment, lack of emotional support and empathy, and abandonment of care. “Violation of Clinical Guidelines and Protocols”, Four important subthemes gave rise to the main theme: Retrospective filling of the labour care guide, disregard for women's rights during childbirth, improper immediate transfers of postpartum mothers by non-healthcare personnel, and lack of informed consent. “Mixed Perception of care” emerged from experiences with positive care, normalization of poor care and showing gratitude despite challenges.

Conclusion

To enhance midwives' care practices and satisfy women's needs and preferences, it is crucial that they get ongoing support supervision and training, with an emphasis on guidelines and woman-centered care. We advise including respect, empathy, accountability, and good communication into every aspect of intrapartum care. This will improve maternal-newborn outcomes, create a positive childbirth experience, and restore women's trust in facility-based birth services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-025-08624-7.

Introduction

Intrapartum care is the support and care provided from the start of active labour (5 cm dilatation with regular uterine contractions) until the complete birth of the placenta and membranes [1]. A crisis in midwifery and childbirth is becoming more widely acknowledged on a global scale, showing pervasive inadequacies in the accessibility, quality, availability, and equity of care for mothers and newborns [2]. To decrease intrapartum-related maternal, fetal, and neonatal morbidity and mortality more rapidly in low-income countries, deliberate measures that concentrate on the stages of labour and birth are required [3]. Even though more women in Uganda are giving birth in health facilities [4], insufficient care continues to impede the achievement of the desired health outcomes [5]. Uganda's maternal and neonatal mortality rate has remained high, with 189 maternal deaths for every 100,000 live births and 22 neonatal deaths for every 1000 live births [6]. For women to have positive birth experiences, safe births and the maintenance of their physical, mental, and emotional health during the intrapartum care phase are crucial.

Adopting a comprehensive, human rights-based and woman-centered care approach can maximize the quality of intrapartum care [1]. For women with low-risk pregnancies, midwife-led care is appropriate, in this case, the midwife serves as the primary healthcare provider [7]. For many years, midwifery care has been linked to offering continuity, support, and a customized approach throughout the labour and birth process [8, 9]. According to studies, midwife-led care is linked to favorable birth outcomes, such as a higher chance of a vaginal birth occurring physiologically, a lower risk of preterm birth, and enhanced satisfaction with care [7, 10–12]. Additionally, it encourages the efficient use of limited healthcare resources and the minimal use of interventions, such as lower rates of episiotomy, epidural, and instrumental births [10, 13–15]. The experience of labour is greatly influenced by midwives, who frequently offer intrapartum care and advice that is focused on the needs of an individual woman. However, midwives' roles and responsibilities are varied and diverse, based on healthcare facilities, cultural factors, and even the behaviors of individual practitioners [16, 17]. The care that midwives give may be impacted by the difficulties they encounter, despite the advantages of continuity of care, including time restraints, workload demands, and negotiating medical hierarchies in hospital settings. Qualitative research enables a more thorough exploration of the subjective and individualized aspects of intrapartum care, it has been crucial in documenting these multifaceted experiences [10]. There is currently a dearth of solid data relating midwives' practices to women's care needs [18]. However, women should currently receive person-centered care and treatment that respects their preferences [1]. In Uganda qualitative research that explores the complex relationship between midwifery practices and mothers’ experiences during intrapartum care, is still lacking as far as the authors are aware. Previous studies have focused on either the experiences of midwives with postpartum care [19], or the experiences of mothers with intrapartum care [3], a few have studied both in tandem. Through direct observations and qualitative in-depth interviews, this research sought to uncover the midwives’ practices while providing care and the mothers’ experiences while receiving intrapartum care. This could produce practical insights for improving care. In light of this, the current study aimed to investigate the intrapartum care practices of midwives and the experiences of women in selected Ugandan health care facilities. This study shed light on the interactions and practices that characterize the intrapartum care experience by combining the providers observed activities with the voices of service users. By exposing inconsistencies in women's experiences and the realities of midwifery practices, the findings should strengthen the body of evidence supporting better quality of care.

Theoretical framework

The WHO Quality of Care Framework for Maternal and Newborn Health [20], which offers a thorough lens for comprehending midwives' practices and women’s experiences during intrapartum care, serves as the foundation for this study. The framework acknowledges that ensuring respectful, person-centered, and dignified care is just as important as implementing evidence-based clinical procedures in order to improve outcomes for mothers and newborns.

Quality intrapartum care is organized around two interrelated domains, according the framework: Care provision: the degree to which care is timely, safe, and evidence-based; this includes having competent human resources, good communication, and the availability of necessary medications, supplies, and equipment. Experience of care: The degree to which women are treated with respect, dignity, emotional support, and decision-making autonomy and free from discrimination, abuse, or neglect. Cross-cutting elements of the health system, including efficient referral networks, skilled personnel, capable leadership, sufficient infrastructure, and accountability procedures, support these two domains [20, 21]. The experiences that women have during childbirth are acknowledged in this theory as a factor that determines the quality of care as well as an outcome. Negative experiences, including abuse, neglect, or a lack of communication, can have long-lasting effects, such as psychological trauma, a decreased trust in the medical system, and a reluctance to seek professional care during subsequent pregnancies [22]. On the other hand, satisfying birthing experiences boost maternal confidence, promote contentment, and encourage the use of intrapartum services.

The WHO framework also emphasizes the crucial role that midwives play as the main intrapartum care providers, especially in LMICs. The expertise, abilities, working environment, and institutional culture of midwives all have a direct impact on how care is provided and experienced. Contextual issues such as lack of workers, heavy workloads, poor training, and limited resources frequently jeopardize adherence to prescribed standards of care in sub-Saharan Africa, and Uganda in particular [2, 23]. This study places women's birth experiences and midwives' practices within a larger framework of accountability and quality improvement by using the WHO Quality of Care Framework as a guide. The approach offers an evidence-based justification for interventions that enhance the technical and experiential aspects of maternity services by enabling inquiries into the ways in which interpersonal and structural elements interact to influence care throughout the crucial intrapartum phase.

Methods

Study setting, design and participants

The study was carried out in three selected Uganda’s primary public health Centre four (IV) facilities where two were rural health facilities and one urban health facility: these are, Bwizibwera Health Centre IV (BHCIV) in Mbarara district, Kinoni Health Centre IV (KHC-IV) in Rwampara District and Mbarara City health Centre IV (MCHIV) in Mbarara City. These three districts have five health Centre IVs out of which three facilities were purposively selected due to the increased number of birth related complications from these health facilities. MCHIV has ten [10] midwives working on the maternity ward, with an average number of 10 births daily. BHCIV has 8 midwives with an average of 6 births per day and KHC-IV 4 midwives with an average of 5 births daily. This was a cross-sectional study design that used exploratory qualitative descriptive inquiry. The constructivist philosophical paradigm served as the foundation for this approach. According to this naturalistic paradigm, the researcher interprets and analyzes what is said and observed. It has been highlighted that finding the precise state of the situation being studied in its natural environment is the goal so that researchers can experience the occurrence and derive meanings [24]. The reason this design was chosen is that it enables the target phenomenon to be seen as it would if it weren't being studied for direct observation [25, 26].

The study was conducted among midwives and labouring, postpartum mothers in selected health facilities from 17th April to 19th May 2025.

Data collection procedure

In this study, nonparticipant direct observation of the midwife providing care and the mother in active labour was used to explore midwives’ intrapartum care practices. Additionally, in-depth interviews with the mother were used to explore her experiences with intrapartum midwifery care received. The in-depth interviews were guided by both the interview guide and observation notes to describe and explain women’s’ feelings regarding the practices that they received and experienced. The data saturation principle, which states that no new information will emerge from later participants, was used to determine the sample size [27, 28]. Based on clinical evaluation, the on-call midwife assessed women who were in labour. A trained research assistant approached the women after their eligibility was confirmed, gave them information, and got their informed consent. The observer did not participate in selection or consent; they merely observed care and recorded observations for purposively selected participants in spontaneously established labour at 5 to 6 cm cervical dilatation, expecting a vaginal physiological birth. Ten [10] midwives were observed while caring for mothers in labour. Fifteen mothers gave their permission and consent to take part in the research. Four of these women were excluded as their delivery process required intervention and led to an emergency cesarean section which prevented follow up on the midwives’ practices throughout the intrapartum care process.

Observation

The trained research assistant informed the midwives about the study every morning as they reported for duty and obtained written consent. On arrival at the maternity unit, a trained research assistant purposively selected one mother who met the eligibility criteria. Mother’s informed consent to observe her care was obtained earlier on admission before active labour. Intrapartum care was examined through nonparticipant direct observations of the mothers receiving care undertaken by the midwife on duty. An observation protocol was used to guide observations during care. The observation protocol was guided by the WHO quality of care framework for maternal and newborn health [20]. Both descriptive and reflective notes were recorded. Descriptive notes attempted to accurately document actual data along with the setting, actions, behaviors and conversations. Reflective notes consisted of records of the observers’ understandings, inquiries and worries during observation [29]. The direct observations made, guided further, the in-depth interview with mothers in the subsequent phase, to express their views on the care received. The direct observations were carried out by KE and KA who are both licensed midwives. The primary observers’ expectations and past experiences were recorded and bracketed in a reflexive journal to improve analytical rigor and reduce their possible impact on data interpretation and study results.

Interview

Mothers who were observed while receiving care, were purposively selected for an exit in-depth interview using an interview guide. To maintain confidentiality and privacy, the interviews were conducted in a private, secure room at each study site. The labour suit and postnatal wards were not connected to this room. The purpose of the interview was to explore mothers’ experiences with intrapartum care received and then data from observations and in-depth interview findings were triangulated. This approach validated and verified data as well as identified inconsistencies in the data sets, and aided attainment of saturation more quickly, collecting detailed information on the phenomenon under study [27, 30–32]. The interview guide questions were developed based on literature regarding women’s needs during intrapartum care and the role and responsibility of the midwife [1]. It consisted of two sections, where section A: entailed socio-demographic characteristics and obstetric history of respondents and section B: consisted of probing questions on mothers’ experiences with the intrapartum care received. In-depth interviews were carried out in a secured room to ensure privacy and each interview session lasted 30 to 45 min.

Data analysis and management

Data were analyzed simultaneously with data collection reflecting and modifying the process of data collection with the subsequent cases [33]. Latent content analysis was used for direct observations data; this enabled in-depth interpretation of the underlying meanings of the text and condensing data without losing its quality [34]. Thematic analysis was applied for in-depth interviews data, and finally, both data sets were triangulated. The results were organized and analyzed using the QoC framework, which offered a conceptual framework for interpreting participant experiences and observed practices. Emerging codes and patterns were analyzed in relation to the framework's central domains of care provision and care experience via latent content analysis of observation data and thematic analysis of interview data. This made it possible to systematically interpret the results in the larger framework of woman-centered, evidence-based, and respectful maternity care. For example, the experience of the care domain was reflected in issues of mistreatment, lack of empathy, and poor communication, whereas the provision of the care domain was connected with non-adherence to clinical guidelines and disregard for women's rights. By connecting observed practices and women's narratives to recognized aspects of high-quality maternity care, the triangulation of the two data sets ensured thorough and comprehensive organization of the results under the QoC framework.

The audio recordings were transcribed verbatim and were anonymized. The researchers familiarized themselves with the data. Analytical notes, thoughts, and reflections were made in this process with the aim of comprehending data collected. Data were then broken down into smaller meaning units (from observation notes and interviews); and each identified meaning unit was labelled with a code, as understood in relation to the objective of the study. Codes were generated inductively; these were compared with the original text to ensure that meaning had not changed [35]. Data were coded manually by EK and AMM; MS provided oversight and confirmed the codes. The codes were grouped into subcategories, categories, and then themes were formulated based on both the data and research question [36, 37]. The analysis was deliberated among all co-authors for clarity. Narrative quotes that best described the various categories were also selected. For rigor and trustworthiness of data, triangulation was conducted by combining observation and interviews, continuous observation, peer de-briefing after data collection, and detailed descriptions. All co-authors contributed to analytical rigor and confirmed the findings. EK, AMM and MS also had reflexive journals to account for potential biases during data collection and analysis [38].

Results

The results presented in this section are based on direct observations of midwives’ practices while providing intrapartum care and in-depth interviews with postpartum mothers that were observed while receiving care. Direct observation notes and direct quotes are presented as evidence of what was observed and the participants’ assertions.

Characteristics of participants

Table 1 shows that a total of eleven (11) mothers were observed while receiving intrapartum care and were interviewed after discharge. The majority of participants were married (n = 10), and (n = 6) had completed primary education. Ten (10) midwives were observed, (n = 8) were Enrolled Certificate midwives at the three health facilities.

Table 1.

Participants’ characteristics

No	Age	Marital status	Education level	Cadre of birth Midwife	Health facility
1	21	Married	Secondary	Enrolled Midwife	MCHIV
2	32	Married	Primary	Enrolled Midwife	KHIV
3	25	Married	Primary	Enrolled Midwife	BHCIV
4	37	Married	Secondary	Registered Midwife	MCHIV
5	18	Married	Primary	Enrolled Midwife	KHCIV
6	25	Married	Primary	Enrolled Midwife	BHC IV
7	19	Married	Primary	Enrolled Midwife	KHC IV
8	28	Married	Primary	Enrolled Midwife	BHCIV
9	20	Married	Secondary	Registered Midwife	MCHIV
10	36	Married	Tertiary	Registered Midwife	MCHIV
11	24	Single	Secondary	Enrolled Midwife	BHCIV

Findings are presented under three themes “Disrespectful and abusive intrapartum care”, “Violation of clinical guidelines and protocols”, and “Mixed perception of care”. The physical practices were primarily determined from direct observation notes and the interviews helped to explore the emotional behaviors of mothers and what they experienced during care. The development of themes is presented in Table 2 below.

Table 2.

Themes, subthemes, categories, and illustrative quotes from direct observation notes (DO) and in-depth interviews (IDI)

Theme	Subtheme	Category	Quotes from direct observation notes and In-depth interviews
	Mistreatment	• Harsh tone and yelling • Not responding to the mother’s needs • Making unprofessional remarks to the mother and companion • Verbal abuse during perennial suturing • Midwife threatening physical violence • Physical abuse	"The midwife exerted verbal pressure on the mother, loudly commanding her to push hard and warning that failure to do so could result in the baby's death." (Observation notes: First child, Certificate midwife) “One of the midwives shouted at me in a rude and thoughtless manner. I was not satisfied”. (Mother, IDI) When I was in labour, I tried to speak to the midwife, but she didn't listen. But the person who had accompanied me into the birth room advised me to push instead of waiting for help from the medical staff. (Mother, IDI) The midwife found when the baby was already on the delivery bed, then she abused me that I did not tell her yet I did” (Mother, IDI) Strongly grabbing one of the mother’s thigh, the assistant slaps the mother’s thigh. (Observation notes: First child, Certificate midwife) "The midwife threatened to beat the mother if she did not stay still in bed during contractions." (Observation notes: First child, Certificate midwife) “The pain was too much, I could not be stable in bed. The midwife warned me that she will beat me if I continue messing myself around. Then I asked her if she will beat and kill me or she will leave some life in me.” (Mother, IDI) "The mother was restless on the delivery bed during suturing the perennial tear. “I will purposefully prick you if you continue to disturb me," the midwife, who was clearly agitated, threatened her ” (Observation notes: First child, Diploma midwife) "A mother comes in crying and asks to be discharged because a midwife has just insulted her." (Observation notes: First child, Certificate midwife) "The midwife confronted me and said I had told her bosses about her. I was upset by this and wanted to be released since I was worried about my baby's safety and thought about going to a private institution." (Mother, IDI)
Disrespectful and Abusive intrapartum care	Lack of emotional support and empathy	• Ignoring women's needs during labour • Tormenting the mother in second stage emotionally • Denying the mother emotional support from the companion • Threatening referral if they disturb the midwife • Not giving reassurance • Using mediators instead of direct engagement • Mother left alone after examination • Lacking proper monitoring during labour • No emotional support or encouragement during labour Disregarding a request that could ease anxiety	"The midwife shouts at the companion (mother in law) to come witness how the mother is going to kill the baby because she was not pushing according to the midwife’s expectation." (Observation notes: First child, Certificate midwife) “She instructed my friend to bring me tea, but she warned her not to stay with me. I started having negative thoughts while I was alone myself” (Mother, IDI) “The pain was much I was not settled in one position, the midwives got annoyed and left me alone…they even brought the paper for me to sign for referral." (Mother, ID) "Midwife told me, 'If you disturb me, I will refer you to the main hospital.' I hated myself." (Mother, ID) "Call a midwife, she asked the attendant. But the midwife stayed in the duty room, replying dismissively via the intermediary, the attendant”. Observation notes: Mother,second child; Diploma midwife) She was left on the examination bed alone without further assistance."( Fourth Child,—Certificate midwife) "The midwives left me alone… they did not come back to check on me, when I felt an urge to push I called them." ( (Mother, ID) "No one explained anything when the pain became worse, I was just left with the companion." (Mother, ID) "Do you want to push out all your organs? Do you want to push out everything you have through this side? Don’t push!" ( Observation notes: Fourth Child, Certificate Midwife) "Do you think we shall be examining your wife every minute?" (Observation notes: husband, Certificate Midwife) "The midwife calls a second midwife to ratify mother's pelvis is adequacy, but the second midwife fails to comply." (Observation notes: Fourth child, certificate midwife) "I had to wait for hours before I was re-examined, no one told me anything." (Mother, ID)
	Abandonment of care	• Delaying to attend to the mother in second stage • Abandoning the mother during critical moments • Absence of skilled birth attendance throughout labour	The midwife directs the mother to lie on the bed in labour suit, examines and tells her to remain on the bed and that if the mother feels like pushing she should call her (in Runyankore: Kukirije onyete). (Observation notes: First child, diploma midwife) I called the midwife that the baby is coming but she did not believe me by the time she came the baby was out on the delivery bed, she abused me”. (Mother, IDI) After examining me she left me a lone and said if feel I like pushing I call her (Mother, IDI)
Violation of Clinical Guidelines and Protocols	Retrospective filling of the labour care guide	• Delayed charting • Post birth charting	“LCG missing in the mother’s file because it was not included on admission” (Observation notes: Mother, third Child, Certificate Midwife) “Mother’s file has the LCG but details were filled only on admission” (Observation notes: Mother, second Child, Certificate Midwife) “Mother gives birth, she is left to rest. Midwife starts documentation of delivery notes; at the same time the midwife retrospectively fills the labour care guide and files it” (Observation notes: certificate midwife)
	disregard for women's rights during childbirth,	• Denying the mother the choice in positioning • Disregarding mother's preferences • Timing of pushing controlled by the provider • Using authority to coerce instead of offering support • Questioning mothers for not going elsewhere for care • Midwife leaving duty without adequate handover • Not providing feedback after examinations • Being Sarcastic • No smiling	“Midwife confirms that the mother is in second stage of labour, directs her to lie in lithotomy position and be ready to push the baby” (Observation notes: Mother second child, diploma midwife) “The midwife told me lie on my back and push the baby. They are the ones who tell us the position to be when pushing the baby”. (Mother, IDI) “The midwife asked me why I did not go to other health facilities which are not busy that for them they are already tired. I did not like her question because this is the facility I used last time” (Mother, IDI) “After directing me to lie on the bed, she checked me and then left me there. She kept what she found with herself” (Mother, IDI) “Midwife asks the mother why she is still putting on knickers while in labour, do you want to give birth while in a knickers? She asks the mother” (Observation notes: Mother first child, certificate midwife) “I did not see any midwife smiling the time I was in labour, I wonder why they don’t smile with us” (Mother, IDI) "I wanted to push but the midwives said I should not, they could not understand me” (Mother ID) "You want to kill the baby by moving your buttocks too much!’" (Midwife, DO) “Mother comes in from ambulating, midwife on duty does not know her because she was not properly handed over” (Observation notes: Mother Second Child, Certificate Midwife)
	Improper immediate postpartum care practices	• Transferring the mother to postnatal ward by the companion • Transferring the mother to postnatal ward before vital observations are taken	"The companion was directed by the midwife to accompany the mother to the postnatal unit following birth. But the mother was taken back for resuscitation after collapsing at the labour ward door” (Observation notes: Mother second child, diploma midwife) “Transferring the mother to postnatal ward before vital observations are taken” (Observation notes: Mother second child, diploma midwife) “They only measured my blood pressure when I came in but did not take any measurements after birth” (Mother, IDI)
	Lack of Informed Consent	• Midwives giving instructions without explaining • Absence of explaining before procedures • Not giving verbal consent prior to procedures	“Without providing any explanation, the midwife instructs the mother to lie down in the dorsal position”. (Observation notes: Mother second child, certificate midwife) “Most times midwives do not explain anything, they tell you sit, climb the bed, get off the bed” (Mother, IDI)
Mixed Perception of Care	Experiences with positive care	• Mothers appreciating care • Mothers comparing care to the main referral hospital • Being present in second stage	“The second midwife was good, she was even calling me by name, she was even answering my questions and I was happy” (Mother, IDI) "Compared to the main hospital, these services are superior”. (Mother, ID) “I am thankful the midwife was good to me, I was only praying that I give birth before she leaves duty” (Mother, ID) “In the main hospital you hardly get a bed after a normal birth they put a mattress on the floor” “Despite their yelling, the midwives were there for me when the baby was about come out”. (Mother, ID)
	Normalization of poor Care	• Mothers downplaying negative experiences • Women accusing themselves of causing providers to act negatively • Believing that mistreatment is reasonable given the situation • Lacking demand for respectful care • Accepting power imbalance between the mother and healthcare provider as normal	"Midwives spoke badly to me during labour, but they are also human beings." (Mother, ID) "I think the midwives get tired when we bother them too much." (Mother, IDI) "We don't have a say in these things; we just do as the midwives say because they know better." (Mother, IDI) "I don't care how they treat me as long as the baby survives." (Mother, IDI)
	Gratitude despite challenges	• Being present in second stage • Being forgiving as a result of a successful birth Showing thankfulness even when mistreated	"Despite all the maltreatment, I was happy when I saw my baby alive." (Mother, IDI) "The midwife was rude, but I thank God she helped me at the time of birth." (Mother, IDI) “When they assisted me in giving birth to my kid, who had a cord around his neck, I was pleased. This made it easier for me to forgive them”. (Mother, IDI)

Disrespectful and abusive intrapartum care

During intrapartum care, instances of disrespect and abusive care were acknowledged. This theme emerged from three sub themes. “Mistreatment” and “Lack of emotional support and empathy” and “Abandonment of care”.

Mistreatment

Mothers in this study described that most of the midwives yelled and used harsh tones during intrapartum period. This can have serious short and long term psychological and clinical consequences.

"The midwife exerted verbal pressure on the mother, loudly commanding her to push hard and warning that failure to do so could result in the baby's death." (Observation notes: First child, Certificate midwife).

“One of the midwives shouted at me in a rude and thoughtless manner. I was not satisfied”. (Mother, IDI).

Mothers recounted that midwives did not respond to their needs most of the time. This lack of response may lead to a reluctance to seek health care in subsequent pregnancies and contribute to maternal complications not being identified.

The midwife found when the baby was already on the delivery bed, then she abused me that I did not tell her yet I did” (Mother, IDI).

Midwives making unprofessional remarks to the mother and companion were also observed and mentioned. There were incidents where the midwives threatened to beat the mothers due the involuntary movements made during contractions. This showed a lack of respect for the mother and caused fear and anxiety and a negative birth experience.

“The pain was too much, I could not be stable in bed. The midwife warned me that she will beat me if I continue messing myself around. Then I asked her if she will beat and kill me or she will leave some life in me.” (Mother, IDI).

Verbal abuse during perineal suturing was also commonly observed. When women made any movement of their bodies during the suturing process, some midwives showed signs of agitation. Midwives frequently gave harsh or reprimanding actions such as ordering mothers to stop moving the buttocks and informing mothers how the midwife will intentionally prick the tear. The mothers did not reply to these responses as they were vulnerable, and it could have been a sign of anxiety, fear, and/or a lack of confidence to speak up during this encounter.

"The mother was restless on the delivery bed during suturing the perineal tear. “I will purposefully prick you if you continue to disturb me," the midwife, who was clearly agitated, threatened her.” (Observation notes: First child, Diploma midwife).

Threatened physical abuse and actual physical abuse existed. In several cases, a midwife threatened the mother verbally, saying that if she didn't stay still on the bed or kept expressing pain, she would physically punish her. Physical violence evidenced by slapping mothers’ thighs was also observed. A coercive approach to patient management and a violation of the principles for respectful maternity care are evident in this interaction.

“Strongly grabbing one of the mother’s thigh, the assistant slaps the mother’s thigh”. (Observation notes: First child, Certificate midwife).

Lack of emotional support and empathy

Mothers recounted that most of the midwives showed a lack of emotional support and empathy. This lack of empathy was manifested through refusing the companion from staying with the mother while in labour,

“She instructed my friend to bring me tea, but she warned her not to stay with me. I started having negative thoughts while I was alone myself”. (Mother, IDI).

During the second stage of labour, midwives were sometimes observed yelling and calling the companion to see what they characterized as the mother's inability to birth the baby on time. Midwives frequently blamed delays on the mother's conduct and accused her of putting the baby's life in danger. Both the mother and her support person seemed to experience mental anguish and confusion as a result of this blaming.

"The midwife shouts at the companion (mother-in-law) to come witness how the mother is going to kill the baby because she was not pushing according to the midwife’s expectation." (Observation notes: First child, Certificate midwife).

When midwives thought mothers were stubborn or rowdy, they frequently threatened to refer them to the main hospital. The women experienced dread and anxiety as a result of these threats, which may have contributed to adverse events on the progress of labour by increasing psychological stress levels.

“The pain was much, I was not settled in one position, the midwives got annoyed and left me alone…they even brought the paper for me to sign for referral which I refused to write." (Mother IDI).

Sometimes the mothers were abandoned where calls for help were ignored by the midwife and this caused confusion and anxiety among mothers and their companions.

"Call a midwife,” she asked the attendant. But the midwife stayed in the duty room, replying dismissively via the intermediary, the attendant”. Observation notes: Mother, second child; Diploma midwife).

I called the midwife to say that the baby is coming but she did not believe me… by the time she came the baby was out on the delivery bed”. (Mother, IDI).

Abandonment of care

Occasionally midwives had a tendency of telling the women to call them when they feel an urge to push. Sometimes midwives ensured their presence only when the head was visible, which indicates a delayed reaction and negligence during a critical part of intrapartum care and intentional absence of skilled birth attendance throughout labour.

The midwife directs the mother to lie on the bed in labour suite, examines and tells her to remain on the bed and that if the mother feels like pushing she should call her (in Runyankore: Kukirije onyete). (Observation notes: First child, diploma midwife).

Violation of clinical guidelines and protocols

This theme captured systematic violations of fundamental clinical and ethical standards that regulate high-quality maternity care. Four important subthemes gave rise to the main theme: retrospective filling of the labour care guide, disregard for women's rights during childbirth, improper immediate transfers of postpartum mothers by non-healthcare personnel, and lack of informed consent.

In contrast to established professional recommendations, there was evidence of most midwives filling out labour care guides retrospectively, documenting only after mothers had given birth. This paperwork may have been completed to satisfy administrative requirements rather than individual mothers’ needs.

“Mother gives birth, she is left to rest. Midwife starts documentation of delivery notes, at the same time the midwife retrospectively fills the labour care guide and files it” (Observation notes: certificate midwife).

Disregard for women's rights during childbirth was observed, where mothers were denied the choice of position in second stage of labour.

“Midwife confirms that the mother is in second stage of labour, directs her to lie in lithotomy position and be ready to push the baby” (Observation notes: Mother second child, diploma midwife).

“The midwife told me to lie on my back and push the baby out. They are the ones who tell us the position to be in when pushing the baby”. (Mother, IDI).

Furthermore, the timing for pushing is controlled by the midwife rather than the mother and questioning mothers for not going elsewhere for intrapartum care.

“The midwife asked me why I did not go to other health facilities which are not busy that for them they are already tired. I did not like her question because this is the facility I used last time”. (Mother, IDI).

“The midwife is the one who told me when to push and when not to do so. Sometimes, I felt like pushing but I had to wait for her instruction” (Mother, IDI).

Additionally, there were significant violations of professional norms in the immediate postnatal care process, when mothers were transferred to the postnatal ward by companions rather than midwives.

There was a lack of informed consent that was frequently observed. Lack of explanations before procedures and the failure to get mothers' verbal permission before conducting clinical procedures was common practice. This lack of informed consent clearly impairs the relationship between the mother and midwife, which is essential for safe decision-making and effective communication during labour.

“Without providing any explanation, the midwife instructs the mother to lie down in the dorsal position”. (Observation notes: Mother second child, certificate midwife)

“Most times midwives do not explain anything, they tell you sit, climb on the bed, get off the bed” (Mother, IDI).

Mixed perception of care

This theme emerged from three subthemes “Experiences with positive care”, “Normalization of poor care” and “Mothers showing gratitude despite challenges”.

Experiences with positive care

According to the findings, some mothers said they were grateful for the attention they received from certain midwives who spoke to them respectfully by using their name and answering their questions. By encouraging a sense of comfort, dignity, and satisfaction with the care they got, these acts enhanced the mothers' experiences.

“The second midwife was good, she was even calling me by name, she was even answering my questions and I was happy” (Mother, IDI).

Several mothers acknowledged that the current facility provided better conditions, especially the availability of beds for sleeping, which contributed to a more positive care experience when comparing the care, they had at the health facility to that of the main regional referral hospital in the area.

“In the main hospital you hardly get a bed after a normal birth they put a mattress on the floor” (Mother, IDI).

Even though midwives had been mostly absent throughout the first stage of labour, some mothers showed gratitude for their support and presence during the second stage. This highlights the value of ongoing support during every stage of intrapartum care.

“Despite their yelling, the midwives were there for me when the baby was about come out”. (Mother, ID).

Normalization of poor care

The findings show that some mothers downplayed negative experiences.

"Midwives spoke badly to me during labour, but they are also human beings." (Mother, ID).

Negative labour experiences were internalized by some mothers, who blamed their own behaviors for the harsh or disrespectful treatment they received from medical professionals. In the context of maternal health, this self-blame demonstrates the normalcy of disrespectful care and implies an absorption of mistreatment.

"We don't have a say in these things; we just do as the midwives say because they know better." (Mother, IDI).

"I don't care how they treat me as long as the baby survives." (Mother, IDI).

Gratitude despite challenges

The results indicate that because the birth outcome was successful, some mothers were more likely to overlook cases of disrespectful care. This trend demonstrates how favorable outcomes results can obscure unpleasant experiences, causing women to lessen or justify inadequate treatment.

"The midwife was rude, but I thank God she helped me at the time of birth." (Mother, IDI).

Even in cases when they had been mistreated, some mothers were thankful for the care they had received. Despite unpleasant encounters, this expression of gratitude could be a result of low expectations for care or a preference for the baby's safe birth over one's own dignity.

“When they assisted me in giving birth to my kid, who had a cord around his neck, I was pleased. This made it easier for me to forgive them”. (Mother, First child IDI).

Discussion

In this study we explored midwives’ practices and mothers’ experiences with intrapartum care. Three themes were identified, “Disrespectful and abusive intrapartum care”, “Violation of clinical guidelines and protocols”, and “Mixed perception of care”.

In the current study, mothers often experienced abusive and disrespectful care throughout the intrapartum period. This abuse and disrespect included threats of physical violence with instances of real physical abuse, like slapping, as well as verbal abuse, including shouting and the use of demeaning or unprofessional language. This finding is in line with previous studies carried out in Tanzania, Ethiopia, East and Southern African study. Nigeria and other low and middle income countries that reported verbal and physical abuse during intrapartum care [22, 39–45]. The occurrence of disrespect and abuse can be attributed to perceptions of women as difficult, stress and burnout among healthcare professionals, facility culture and lack of accountability, inadequate facility infrastructure, including a shortage of drugs and supplies, and provider attitudes [46]. This kind of abuse can increase anxiety and stress, which can lead to a traumatic birth experience, in addition to undermining women's dignity. Respectful maternity care (RMC) models, on the other hand, place a strong emphasis on the value of comforting, supportive communication, which has been associated with improved maternal outcomes and satisfaction [47]. The culture of power, fear, and blame that frequently accompanies disrespectful care may be reduced significantly by incorporating RMC concepts into training and service delivery.

A substantial lack of emotional support was also observed, as several midwives threatened to refer the mothers to other health facilities if they were thought to be unruly. Referral threats demonstrate a punitive rather than a caring approach to care. It is well known that providing emotional support during labour can enhance the quality of the birth and lessen the need for medical interventions [48–50]. In the current study midwives weaponised emotional neglect, which could reinforce women to internalize blame and make it harder for them to speak up for themselves during labour. The prospect of referral is also occasionally used to silence women or reduce workload, according to recent research conducted in Uganda [51]. This approach goes against the principles of patient-centered care and compromises continuity of care. As a result, we advise important stakeholders to improve provider training about patient-centered communication and RMC, with an emphasis on ethical utilization of referrals. Midwives should be taught to see referrals as clinical judgments made with the mother and baby’s best interests in mind, rather than as a form of punishment or disciplinary action.

Violation of clinical guidelines and protocols is reported in the current findings. The fact that midwives complete the LCG after the infant is born, instead of during labour, raises questions about the standard of intrapartum monitoring and clinical protocol adherence. This issue is analogous to earlier studies conducted in Ethiopia and South Asia that documented both retrospective completion and formality of labour monitoring instrument completion [52, 53]. This retrospective record keeping may be attributable to a possible absence of an accountability culture, where documentation is viewed as a usual duty rather than an essential part of care [52]. Therefore, education and training programs need to emphasize the LCG's clinical value as a tool for decision-making rather than just a documentation necessity.

When companions, not midwives, moved mothers to the postnatal ward during the initial postnatal care procedure, there were serious breaches of professional standards. Similar findings have been documented in a number of studies conducted in settings with limited resources, where mothers are forced to go to a postnatal ward by walking and frequently with little assistance from health care providers soon after giving birth [22, 54, 55]. Due to a lack of strong systems for accountability, risky practices might become common in certain settings when patients and health care providers have internalized low expectations [54]. WHO encourages considerate, supportive care, which includes preserving maternal dignity and helping with mobility, particularly for mothers who are weak or recuperating from exhausting labour [1]. Therefore, we advise that respectful maternity care education and training be introduced or reinforced for all midwifery cadres, with a focus on immediate postpartum support, safety, and dignity.

Poor handover between shifts was observed. This finding confers with previous studies where a number of women’s care were not handed over in Gambia and Uganda where maternity handovers were inadequate [56, 57]. This issue may be connected to a shortage of workforce causing hurried shift changes, lack of defined handover tools or communication methods and inadequate accountability and supervision systems [5, 22, 54]. Thus, there is need to provide frequent audits of shift change protocols, adhere to clinical guidelines and policies, training personnel on efficient handover strategies, and institutionalize structured handover tools to guarantee clear, succinct communication throughout care transitions.

Many women complained that, despite their own comfort level or medical necessity, they were told to give birth in the lithotomy position. In addition to undermining woman-centered care, this type of coercion and lack of choice can result in negative birth experiences. WHO recommends that, unless there is a contraindication, women should be free to select the position in which they give birth [1]. It has been demonstrated that limiting the mother's options for the birth position is linked to decreased satisfaction and a diminished sense of dignity during intrapartum care [43]. Provider convenience and traditional midwifery training that favors lithotomy position, lack of awareness of the research supporting alternate positions, and the lack of equipment or space in facilities to accommodate upright or lateral positions for birth can all be attributed to RMC [58]. As a result, we advise educating midwives and other healthcare professionals on evidence-based intrapartum care prioritizing maternal autonomy, and enhancing facilities to accommodate different birthing positions.

The findings of this research point to shortcomings in midwives' informed consent practices. A considerable number of participants stated that there was commonly a lack of informed consent, which was typified by inadequate explanations before clinical procedures and a failure to get mothers' verbal approval. The issues found in this study are consistent with research from other international situations. According to a Cochrane analysis, routine intrapartum care frequently ignores respectful communication, especially when it comes to informed consent, which negatively impacts women's birth experiences [59]. In a similar vein, a Tanzanian study found that many labouring women felt uninformed and powerless, underscoring the need for better communication techniques[55]. These actions violate the fundamental values of respectful maternity care, which are patient-centered care and respect for maternal autonomy[1]. Together, these studies underscore the ongoing global problem of providing ethical and respectful intrapartum care, highlighting the need for structural changes to protect women's rights and raise maternal satisfaction.

Mixed perception of care emerged in the current findings. This theme is in line with a previous study in Tanzania which identified positive interactions between midwives and women [42]. The current study findings to support this theme are contrary to a study carried out in East and Southern Africa which reported that many women experienced poor interactions with labour and birth care providers [43]. Supportive interactions between midwives with women during the intrapartum period can help reduce the emotional stress related to labour, thus lowering the chances of trauma-related outcomes, such as postpartum psychological issues [60]. Therefore, it is crucial to educate and train midwives in effective communication skills and patient-focused care to enhance respectful and supportive maternity services.

The belief held by many mothers that the present facility provided better conditions, particularly with regard to the availability of beds for resting before and after birth, highlights how much physical infrastructure affects women’s overall experience of maternity care. According to earlier studies, women's comfort, privacy, and dignity during labour and birth have been compromised by a lack of basic infrastructure, such as beds, and congestion [47, 61]. Perceptions of respectful intrapartum care can be greatly improved by even small infrastructure improvements, as evidenced by the preference of mothers for better sleeping arrangements at the current facilities. The WHO framework for quality maternity and newborn care, which identifies physical infrastructure as a fundamental element of efficient and compassionate care, supports this finding [20]. Additionally, one of the elements impacting respectful perinatal care, according to a prior systematic review, is physical infrastructure [62].

We advise making investments in basic facility infrastructure, such as beds, hygienic bedding, and sufficient space, to lessen crowding and enhance the comfort of women. Plans for improvement should be informed by the views and experiences of women to ensure that their needs are met.

Despite the midwives' lack of presence during the first stage of labour, some of the mothers expressed gratitude for their support and presence during the second stage. This is congruent with the global previous study, that reported women, were repeatedly left unattended in early labour, but still viewed any assistance during actual birth as respectful care [22]. Similarly a study conducted in Tanzanian health facilities, found that women positively perceived intermittent presence of skillful birth attendants as long as there was safer birth outcomes [54]. The current study finding concur that mothers may accept suboptimal standards of care and consequently regulate their expectations, often accepting late-stage care as satisfactory. On the contrary, WHO encourages continuous presence of a skilled birth attendant during intrapartum care for a positive birth experience [1]. Thus, the gratitude voiced by mothers should not disguise the systemic inefficiencies in providing continuous, woman-centred care throughout labour.

Substandard care was normalized, as evidenced by the fact that respondents often minimized their bad experiences and, in certain cases, blamed their own behavior for the substandard care they received. This is similar to earlier research undertaken in Kenya, Tanzania and Nigeria showing that women tended to consider disrespect and abuse to be a normalized practice in health facilities [63–66]. This normalcy of substandard care can be attributed to low expectations brought on by frequent exposure to poor services and a lack of awareness about women’s rights [22]. In order to empower women to advocate for dignified and respectful care and treatment during childbirth, public health education programs should be put in place to inform them about their rights to health care and the anticipated standards of maternity care.

According to this current study, despite experiencing abuse, or neglect, many respondents expressed gratitude just for surviving childbirth or giving birth to a living newborn. This expressed gratitude is in line with previous studies which showed that women were thankful despite the mistreatment [22, 67]. This phenomenon is frequently ascribed to a few factors; first a long-standing power disparity between women and health professionals during childbirth deters serious criticism of the quality of service. Second, surviving childbirth is viewed as an accomplishment in situations where maternal mortality is high, overshadowing negative components of the birthing process. Third, women lack the comparison framework necessary to question the status quo due to a lack of choice in health care and a general acceptance of abuse as "just the way things are."[22, 54, 67]. Therefore, it is vitally important that maternal health programs should incorporate RMC for all service delivery levels in order to address this disrespectful care.

Strengths and limitations

The use of triangulation in data collecting reduced researcher bias and presumptions that might have affected the study's findings. The interviews took into consideration the women's opinions and emotions. These results helped to clarify the differences between the midwives' actions during childbirth and what women desired. Like any other study, we had some limitations. The results of the study might have been influenced by the observer's own social desirability. A reflexive journal was used to bracket the primary observer's expectations and personal experiences. The Hawthorne effect was expected to occur during direct observations; efforts were taken to reduce the impact of observation on midwives' behavior and it appeared like commonly occurring practices were observed. Specifically, midwives were reassured that data collection was anonymous and that information about their individual performance was not meant to be shared publicly or reported to supervisors. Furthermore, midwives were informed of the overall purpose of the study though they were not aware of the particular elements included on the protocol for the observation. This made them less likely to alter their actions in response to being observed. The observer spent more time observing midwives getting used to the observers’ presence. This helped them to behave naturally overtime. Additionally, in order to address the impact of an unfamiliar person (a non-participant observer) in the labour suit on the data collected, habituation visits were made. Before beginning the actual data collection, the observer had visited the labour ward several times. This made it easier for midwives to become accustomed to her presence. To avoid compromised professional relationships, the research assistants were not working at the study health facilities. Further research should explore midwives’ experiences with intrapartum care.

Implications of the study

Disrespectful intrapartum care and disregard for clinical guidelines can lead to psychological distress, increase health risks, and reduce public confidence in the healthcare system. When women have mixed perception of care, they may normalize inadequate care, particularly if the baby is born healthy. This normalization may mask structural problems and prevent responsibility and accountability. In order to improve care, midwives’ education, vigilant supervision, women’s empowerment, community engagement, and the implementation of respectful care guidelines are all necessary.

Conclusion

The continuation of disrespectful care, non-adherence to clinical guidelines/protocols, and mixed perception of care during intrapartum care reflect inherent systemic flaws within maternity care. These issues erode women's trust and involvement with health care in addition to compromising maternal and newborn outcomes. A multifaceted strategy emphasizing woman-centered, evidence-based, and respectful care is required to address these challenges. Improving the quality and equality of maternal health care requires improving provider capacity, implementing accountability systems, and cultivating a professional and compassionate culture.

Abbreviations

ANC

Antenatal care

LMICs

Low income countries

WHO

World Health Organization

ICM

International confederation for midwives

Authors’ contributions

EK conceived and designed the study. EK, AM and MS implemented the study and conducted data analysis. EK, AM and MS interpreted study results: EK wrote the first draft of the manuscript. EK, AM, and MS reviewed and corrected the draft manuscript. All authors read and approved the final manuscript.

Funding

The study received no funding.

Data availability

The data that support the findings of this study are available from the first and corresponding author.

Declarations

Ethics approval and consent to participate

The Uganda National Council for Science and Technology (UNCST) granted ethical approval (UNCST) HS5048ES, while Bishop Stuart University in South Western Uganda served as the supervising institution (BSU-REC-2024–325). The University of Port Harcourt Research Ethics Committee in Nigeria also provided ethical approval (UPH/CEREMAD/REC/MM94/045). This study adhered to the Declaration of Helsinki's principles and regulations by protecting participants' rights and maintaining ethical standards to ensure their safety and maintain their health [68].

Written informed consent was obtained from the midwives as they reported on duty before observation. Mothers’ written informed consent was obtained by the trained research assistant on admission before active labour. Participants were guaranteed the highest level of confidentiality regarding the handling of acquired data. In order to honor the respondents' desires, mothers and midwives were free to leave the study at any point during the study. A counselor was recruited at each selected facility to counsel mothers that appeared emotionally distressed. Every technique was used in compliance with the applicable rules and regulations. For reasons of confidentiality, the study's results were kept on a password-protected computer.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.