Promoting respectful maternity care in Nepal: a qualitative exploratory study of a pilot forum play intervention with hospital staff

Abstract

Background

Promoting respectful maternity care is a crucial indicator of quality maternal healthcare. However, evidence from global studies indicates that 22% -100% women experience at least one form of disrespect and abuse during facility-based births, with research conducted in Nepal reporting a prevalence of 100%. Therefore, implementing targeted interventions for healthcare providers is essential to reduce instances of disrespect and abuse of women and to foster respectful maternity care. Forum Play represents a promising approach in this regard.

Objectives

To explore the staff perspectives on disrespect and abuse of women during facility-based births and to assess the feasibility and acceptability of a Forum Play intervention in promoting respectful maternity care in Nepal.

Methods

Three half-day Forum Play workshops were conducted among hospital staff of a tertiary hospital in Kathmandu, Nepal, in November 2023. Eleven doctors, 14 nurses and 11 administrative staff were recruited for the workshops by using purposive sampling. Separate workshops were organized for the respective groups. At the end of each workshop, a focus group discussion was conducted using a semi-structured interview guide. All discussions were audio-recorded and non-verbal cues were noted by two note-takers. A total of 27 hospital staff participated in the discussions, including seven administrative staff, 10 doctors, and 10 nurses. Data analysis utilized inductive qualitative content analysis, allowing codes and categories to be developed directly from participants’ responses as guided by Graneheim and Lundman.

Results

Data derived from the focus group discussions was divided into two parts: (i) staff perspectives on disrespect and abuse of women during facility-based births and (ii) Staff reflection on Forum Play in promoting respectful maternity care. Four categories were generated from the data: (1) Structural and systemic drivers of disrespect and abuse, (2) Social and interpersonal determinants of disrespect and abuse, (3) Personal and professional transformation through Forum Play, (4) Acceptance and institutional feasibility of Forum Play. These categories were extracted based on 11 subcategories classified from the codes derived from the data. Participants’ reflections on the Forum Play workshop were very promising. Forum Play was identified as an innovative, interesting and acceptable method of intervention.

Conclusion

Disrespect and abuse during facility-based births arise from structural, social, and interpersonal factors and violate women’s fundamental human rights. Participants’ reflections indicate that Forum Play is an innovative and acceptable intervention that can raise awareness and support personal and professional growth among healthcare providers, suggesting its potential as a practical approach for promoting respectful maternity care. However, further testing is needed to confirm its feasibility and effectiveness.

Introduction

Global evidence indicates that the rate of skilled birth attendance and facility-based births is increasing. However, even after arriving at a health facility, many women and their newborns lose their lives due to inadequate, and poor-quality care [1]. Most maternal and early newborn deaths can be avoided through timely and respectful care [2]. Disrespect and abuse during facility-based births remain a widespread global concern and are particularly prevalent in low- and middle-income countries, including Nepal [3–5]. Studies from multiple low- and middle-income countries report that 22% to 100% of women experience at least one form of disrespect and abuse during facility-based births, with prevalence ranging from 22% in Northern Ethiopia to 100% in central Ethiopia and eastern Nepal [5–10]. The widespread occurrence of disrespect and abuse of women during facility-based births has driven a global movement since 2011 to promote Respectful Maternity Care (RMC) as a fundamental human right [4, 11].

Nepal continues to face high maternal mortality (151 deaths per 100,000 live births) and neonatal mortality (21 deaths per 1,000 live births), among the highest rates in Asia [12, 13]. To align with the Sustainable Development Goals (SDG) 3.1 and 3.2, the country has committed to reducing maternal mortality to 70 per 100,000 live births and neonatal mortality to 12 per 1,000 live births by 2030. Recognizing that universal access to skilled birth attendance is central to achieving these targets, the Government of Nepal aims to increase the rate of institutional deliveries from 79% in 2022 to 90% by 2030 [14]. A key strategy to encourage more women to give birth in health facilities is the assurance of RMC, as women are less likely to seek facility-based births when they receive care that undermines their dignity and rights. Although the 2018 Safe Motherhood and Reproductive Health Right Act provide a legal framework for RMC in Nepal [15], disrespectful practices persist due to entrenched hierarchical relationships, systemic constraints, limited staff training, and heavy workloads [16].

There is a growing number of studies exploring disrespect and abuse of women during facility-based birth and the perspective of health care providers towards RMC [3, 17–19]. However, most studies have primarily focused on documenting the prevalence and forms of disrespect and abuse, with limited evidence on context-specific, interactive, and behavior-change-oriented interventions to promote RMC, particularly in low-resource settings such as Nepal [3, 4, 20]. A systematic review on RMC interventions has highlighted that interventions conducted in some countries to minimize disrespect and abuse of women during facility-based births are effective [21]. Forum Play workshops have previously been used as an intervention to enhance care providers’ knowledge and promote behavioural change regarding abuse in healthcare in Sri Lanka and Sweden showing promising results [22–24]. Forum Play is a participatory, role-playing method that allows healthcare providers to actively rehearse real-life scenarios themselves, reflect on their actions, and explore alternative approaches. By combining experiential learning with peer feedback, it promotes empathy, critical thinking, and self-directed behavioral change [25]. Behaviour change interventions among care providers are pivotal to promoting RMC, yet evidence on effective strategies to reduce disrespect and abuse in low-resource settings like Nepal is scarce. Few studies have explored the feasibility, acceptability, or context-specific adaptations of participatory, experiential interventions such as Forum Play [22–24], and it has not previously been implemented in Nepal. Given its focus on social and behavioural drivers of disrespect and abuse, Forum Play is particularly suited to address these complex factors [25]. Therefore, we conducted this pilot Forum Play intervention in Nepal as an initial step to introduce RMC intervention, aiming to promote behavioural change among care providers.

This study, part of a pilot Forum Play intervention, explored hospital staff perspectives on disrespect and abuse during facility-based births and assessed the feasibility and acceptability of using Forum Play to promote RMC. Related studies from the same pilot intervention have focused on different aspects: a pre- and post-test study examined the effectiveness of Forum Play on self-reported perceptions and behaviour among care providers in urban Nepal, while a one-year mixed-method follow-up evaluated the longer-term impact and reflection on the intervention. This paper, therefore, specifically reports on the qualitative findings on staff experience and the feasibility of implementing Forum Play in the Nepalese context.

Methods

Study design and setting

A qualitative study was conducted based on the pilot intervention of Forum Play in a tertiary hospital at Kathmandu, Nepal. This hospital has implemented the Safe Motherhood Program, Nepal’s national maternal health initiative, which provides free delivery services, transportation incentives, and antenatal care benefits to reduce barriers for pregnant women in accessing quality facility-based care. On average, this hospital conducts 1,500 deliveries per year, including Cesarean sections. The study employed an inductive qualitative content analysis approach and was guided by a constructivist paradigm.

Population and sampling

Doctors, nurses and administrative staff who are directly or indirectly involved in caring for women during labour and childbirth were purposively selected for the study. Inclusion criteria included hospital staff currently working in maternity, obstetrics, neonatology, or administrative units related to maternal care, with at least one year of work experience, and willingness to participate in the study. The inclusion criteria were guided by the need to capture perspectives from key stakeholders involved at multiple levels of maternal healthcare delivery. Doctors and nurses are directly involved in providing care during labour and childbirth, whereas administrative staff play a role in shaping institutional policies, allocating resources, and influencing the overall care environment. Including all three groups made it possible to capture both the clinical realities and the broader organizational factors that affect RMC.

A total of 45 participants (15 from each group) were invited to take part in the Forum Play workshops. Of these, 36 hospital staff ultimately participated, including 11 administrative staff, 11 medical doctors (six from Gynaecology/Obstetrics, three from Anesthesiology, and two from Neonatology), and 14 nurses from maternity and neonatology units. Among them, 27 staff members took part in the focus group discussions. This number was deliberately kept manageable to support effective interaction and to ensure that participants were willing to stay for an additional hour after the three-and-a-half-hour workshop. This helped facilitate more focused and in-depth discussions while still capturing perspectives across all staff groups. Although the initial sample size was informed by the planned workshop structure, data collection and analysis were carried out concurrently. Sampling continued until data saturation was reached, that is, when successive discussions did not generate new meaningful insights.

Intervention

Three half-day Forum Play workshops were conducted in November 2023 among doctors, nurses, and administrative staff separately. Forum Play is a participatory theatre-based method developed in Sweden by Katrin Byréus [26], inspired by the Theatre of the Oppressed by Brazilian theatre practitioner Augusto Boal [25]. It enables participants to explore real-life experiences of oppression and rehearse alternative responses through active participation.

The intervention was grounded in Sexual and Reproductive Health and Rights (SRHR) [27], and adapted principles from Pedagogy of the Oppressed by Paulo Freire [28] and Theatre of the Oppressed by Augusto Boal [25] to the healthcare context. These frameworks collectively emphasize critical reflection, empowerment, and active participation to challenge oppressive practices in healthcare. Drawing on these principles, Forum Play provided healthcare providers with a structured space to reflect on power dynamics, recognize violations of SRHR, and rehearse and generate more respectful and rights-based care practices.

An experienced Swedish drama pedagogue (third author) facilitated all workshops, with support from interpreters when needed. She has prior experience facilitating interventions in Sweden and Sri Lanka addressing abuse in healthcare, which informed the design and delivery of the workshops. Two local theatre practitioners participated to build their own capacity in Forum Play, provide contextual theatrical insights, and co-lead the Forum Play workshops alongside the Swedish Drama Pedagogue. The workshops were conducted in English for doctors, and in Nepali for nurses and administrative staff, with the assistance of two language facilitators. The PhD candidate participated in the Forum Play workshops as a participant, documenting the experiences shared by participants on meta cards. She also moderated the focus group discussions that followed each workshop. She did not facilitate the Forum Play activities herself, ensuring a clear distinction between facilitation and data collection roles.

Each workshop followed a structured process. Participants first reflected on and shared experiences of disrespect and abuse during labour and childbirth. These narratives were documented (Fig. 1) and used to co-create short, dramatized scenarios. Before enacting these scenarios, participants engaged in warm-up exercises involving movement, posture, voice, and miming. The warm-ups served both symbolic and practical purposes: they prepared participants physically, mentally, and emotionally, fostered group cohesion, and created readiness for active engagement in the Forum Play scenes.

Fig. 1.

Examples of stories shared by the participants

Through a participatory selection process, two key scenarios in each workshop were enacted in small groups and then performed for the wider group (Fig. 2). Participants acted as “spect-actors,” simultaneously observing, intervening, and experimenting with alternative behaviors to counteract disrespect and abuse. They were invited to interrupt performances, assume roles, and explore different approaches to promote respectful care. In doing so, spect-actors used not only verbal interventions but also non-verbal strategies, such as gentle touch, eye contact, and body positioning, to model more respectful interactions. Several alternatives were explored by different spect-actors to identify practical ways of improving care. This interactive process allowed participants to critically reflect on routine practices, power dynamics, and communication patterns, while actively rehearsing respectful alternatives in a safe, participatory environment.

Fig. 2.

Workshop participants playing role

Data collection

Before starting the workshop, participants were asked to fill in a structured questionnaire on participants’ views of disrespect and abuse, and their perception of RMC. After the workshop, a focus group discussion was conducted among all three groups. The focus group discussions were conducted immediately after each Forum Play workshop on the same day, allowing participants to reflect on their experiences while the workshop content was still fresh. Each workshop lasted an average of three and a half hours, and each focus group discussion lasted about one hour. A total of 27 hospital staff including seven administrative staff, 10 doctors and 10 nurses participated in the discussions. Workshops and focus group discussions were held separately for doctors, nurses, and administrative staff due to the hierarchical structure in Nepalese healthcare. Separate sessions encouraged open discussion on sensitive issues like disrespect and abuse, fostering honest reflection and deeper engagement. We used a semi-structured interview guide for the focus group discussions which included questions related to disrespect and abuse, RMC and the Forum Play intervention. The interview guide was mainly based on Midwives’ perspectives of RMC during childbirth [29], and pilot interventional studies conducted in Sweden and Sri Lanka using Forum Play [22–24]. The example of guiding questions and key discussion topics are presented in Table 1. The first author facilitated the discussion as moderator. Main and probing questions were posed to the participants to elicit detailed information relevant to the research questions and to enhance the rigor of the data. The discussions were audio-recorded and the non-verbal communication, along with special moments, were noted down by two note takers. The whole process was observed and guided by the supervisors.

Table 1.

Example of guiding and discussion questions

Headline	Main question	Probing questions
Evaluation of Forum Play	What are your reflections on the Forum Play workshop?	1. Can you describe your experience as participant of the Forum Play workshop? o How did you feel during different parts of the session? 2. How acceptable do you think this approach is in promoting respectful maternity care? o What aspects made it more or less acceptable? 3. How do you perceive the feasibility of implementing Forum Play in your workplace? o What conditions would need to be in place to make it workable?

Data analysis

Sociodemographic variables of the participants were analysed descriptively by using IBM SPSS version 20. The qualitative data were analysed using the inductive qualitative content analysis approach, as described by Graneheim and Lundman [30]. First, all focus group discussions were transcribed verbatim in Nepali and subsequently translated into English. The transcripts were read repeatedly to achieve immersion and a comprehensive understanding of the data. Meaning units, defined as words, phrases, or sentences related to the same central meaning, were identified from the text. These meaning units were then condensed while preserving their core meaning and labelled with codes. The codes were compared based on similarities and differences and grouped into subcategories. These subcategories were further abstracted and organized into broader categories that represented the manifest content of the data (Table 2). The data analysis process was conducted manually. To enhance credibility and minimize researcher bias, all authors were actively involved in coding, discussing discrepancies, and reaching consensus on subcategories and categories.

Table 2.

Example of meaning unit, condensed meaning unit, codes, subcategory and category

Meaning unit	Condensed meaning unit	Codes	Subcategory	Category
P: Forum Play is helpful to us to improve our own behavior ourselves. The role play helped us to realize our weaknesses	Forum Play fosters self-reflection and awareness of personal behavioral gaps.	Self-awareness through role play, self-evaluation and professional self-reflection, realization of own mistakes.	Self-reflection and behavioural change	Personal and professional transformation through Forum Play

The ontological and epistemological position underpinning the analysis was constructivism. From an ontological perspective, reality is viewed as socially constructed through interactions; thus, disrespect and abuse were understood as phenomena shaped by institutional, cultural, and contextual factors. From an epistemological standpoint, knowledge was co-created through the interaction between researchers and participants [31]. Accordingly, the findings developed through participants’ critical reflection on their lived experiences during the Forum Play workshop rather than the researchers objectively extracting them.

Ethical considerations

Ethical approval for the study was obtained from the institutional review committee of the hospital where the pilot intervention was conducted (Ref. 29092023/01). We followed the ethical principles in accordance with the standard of Helsinki declaration to conduct this study. Permission for the workshop was given by the hospital authorities, and the participating departmental heads were asked to provide a list of participants one week before the workshop. An information sheet containing details about the workshop was given to each participant and written informed consent was taken prior to the workshop. All the focus group discussions were audio recorded with the permission of participants and all the audio files were securely stored. Confidentiality of the participants was fully maintained. Considering the sensitivity of the issue, the name of the hospital has not been disclosed anywhere.

Results

The mean age of the participants was 32.25 years, ranging from 21 to 62 years. The majority of the participants (74.1%) were female, more than half of the participants (51.9%) belonged to the Brahmin and Chhetri caste and the majority of the participants (59.2%) were married (Table 3). The median work experience of the participants was 5 years.

Table 3.

Background information of the focus group discussion participants (N = 27)

Variables	Frequency	Percentage (%)
Sex
Male	7	25.9
Female	20	74.1
Ethnicity
Brahmin & Chhetri	14	51.9
Janajati	10	37.0
Madheshi	3	11.1
Marital status
Married	16	59.2
Unmarried	11	40.8
Highest education
Secondary level	3	11.1
Proficiency certificate level	4	14.9
Bachelor	10	37
Masters	10	37
Occupation
Doctor	10	37
Nurse	10	37
Administrative staff	7	26

From the qualitative data analysis, four categories and eleven subcategories were developed (Table 4), capturing staff perspectives on disrespect and abuse during facility-based births and their experiences with Forum Play. Illustrative quotes are provided, with terms such as most, many, and few participants indicating the relative prominence of each category. The findings are interpreted in light of SRHR principles and the pedagogical approaches of Pedagogy of the Oppressed and Theatre of the Oppressed, highlighting how systemic, social, and interpersonal factors shape care practices and how reflective, participatory learning can foster personal and institutional transformation toward RMC.

Table 4.

Codes, subcategories and the categories

Codes	Subcategories	Categories
Workload-related stress, overburdened staff, emotional strain, stress-induced rude behavior, justified verbal harshness under pressure, chaotic labour environments and emergencies, inadequate manpower, especially during crises	Resource constraints and staff stress	Structural and systemic drivers of disrespect and abuse
Mortality-focused care, neglect of maternal well-being, cost-driven compromises in care, especially in free services, exclusion of pain relief due to affordability, emphasis on numbers over experience, over-medicalization and premature decision-making	Outcome-centered and cost-driven care
Poor patient counseling, lack of informed consent, language barriers, cultural discrimination, breach of confidentiality and privacy, communication gaps due to complex medical language, lack of protocols for clear, respectful information delivery	Inadequate infrastructure and communication system
Preferential treatment for paying or private patients, discrimination based on education or rural background, provider bias and rude behavior toward poor or uneducated women, unequal information sharing and communication inequity	Socioeconomic and educational discrimination	Social and interpersonal determinants of disrespect and abuse
Uncooperative patient behavior during labour, normalization of mistreatment for “better outcomes”, verbal control of women during pain expression, justification of abuse due to emergencies or non-compliance	Patient-providers interaction and behaviour
Ignoring women’s voices and choices, lack of pain relief, silencing labour pain, underestimation of women’s understanding, structural neglect of labour pain, violation of bodily autonomy and non-consented care	Neglect of women’s pain and autonomy
Self-awareness through role play, self-evaluation and professional self-reflection, realization of own mistakes, identification of personal weaknesses, behavioral correction, motivation for self-improvement, recognition of disrespectful behavior, empathy development, patient-centered care	Self-reflection and behavioural change	Personal and professional transformation through Forum Play
Empowerment through awareness, encouragement to speak up, personal responsibility for change, professional responsibility, politeness in communication, equal and respectful behavior, empowerment to act against abuse	Empathy development and perspective-taking
Awareness of RMC and its importance, shift in perception and acceptance of respectful care, improved interpersonal and counseling skills, understanding patient perspectives, value of humanization, minimal-intervention care, real-life relevance and reinforcement of professional roles	Awareness of respectful maternity care
	Experiential and participatory learning approach	Acceptance and institutional feasibility of Forum Play
Uncertainty of feasibility, need for institutional support, recommendation for regular workshops, hospital-wide training and sensitization, integration into all wards and policy-level commitment, structured implementation and sustainable change, inclusive training for all staff, institutional adoption of Forum Play	Institutionalization and system-wide application

Part I: staff perspectives on disrespect and abuse during facility-based births

In the first half of the focus group discussion, the participants were asked to discuss their views on disrespect and abuse of women during facility-based births. They expressed that disrespect and abuse of women during labour and childbirth is a violation of basic human rights.

“Abuse of women is the violation of basic human rights of getting proper treatment” (P7, Doctors).

Category 1: structural and systemic drivers of disrespect and abuse

This category was discussed by most participants across all professional groups, who emphasized that disrespect and abuse are not only a result of individual attitudes but are deeply embedded within structural and systemic conditions of care. Participants explained that abusive practices are not usually intentional but are largely shaped by the difficult conditions in which they work. Factors like heavy workloads, limited resources, and systemic pressures influence how care is provided, sometimes leading to less respectful interactions. These challenges also point to wider issues in ensuring women’s SHRH, particularly their right to dignified and respectful care.

Resource constraints and staff stress

Most participants, especially doctors and nurses, described heavy workloads, staff shortages, and frequent emergencies as key contributors to stress. They explained that this pressure can sometimes lead to unintentionally harsh or rude behaviour. Although they recognized that such behaviour undermines respectful care, it was often framed as a response to the demands of the situation rather than a deliberate act.

“Abuse can also occur due to busy schedules and workload. Sometimes, despite knowing this, we behave rudely due to stress” (P4, Nurses)

These narratives suggest that institutional pressures shape everyday practices, with efficiency during critical situations often taking priority over interpersonal care, potentially compromising women’s right to respectful and dignified treatment.

Inadequate infrastructure and communication systems

Many participants highlighted infrastructural limitations, including lack of adequate space, insufficient manpower, and absence of effective communication systems. These constraints were described as barriers to ensuring privacy, proper counseling, and informed consent.

“Actually, keeping mother and neonate in the same room is very good but we know our hospital is so congested that it is near impossible.” (P10, Doctors).

Many participants highlighted significant gaps in communication and respect for women’s rights during labour and childbirth. Language differences and the use of complex medical terminology further limited women’s ability to understand and participate in their care.

“Women do not get adequate information and proper care due to language barriers.” (P8, Nurses)

“All patients don’t understand the medical terms that doctor and nurse use. …. when asked repeatedly, they become irritated and answer rudely.” (P6, Admin Staff)

These findings indicate that communication gaps are not only interpersonal but also structurally produced, limiting opportunities for dialogue between providers and women and undermining women’s right to information and informed decision-making, which are key components of SRHR.

Outcome-centered and cost-driven care

Several participants, mainly doctors, described a dominant institutional focus on clinical outcomes, particularly survival, often at the expense of women’s emotional well-being and childbirth experience. Resource constraints and cost considerations were perceived to influence decisions, including limited use of pain management and increased medical interventions.

We are driven by numbers. ………yes, the mortality rate has decreased, and institutional deliveries are increasing but if they do not get the respectful care they deserve, it is useless.” (P8, Doctors).

Such accounts reflect a system where biomedical priorities overshadow relational aspects of care, potentially neglecting women’s right to quality and person-centered care within the SRHR framework.

Category 2: social and interpersonal determinants of disrespect and abuse

This category was discussed by many participants, highlighting how broader social hierarchies and everyday interactions shape the provision of care, often influencing equitable access to RMC.

Socioeconomic and educational discrimination

Many participants reported that women’s socioeconomic status and educational background influenced how they were treated. Participants reported that women perceived as educated or financially better off were more likely to receive respectful communication, while disadvantaged and marginalized women were more likely to experience neglect or dismissive attitudes.

“Women in the Terai region (south area/plain area) of Nepal often have low socio-economic status, and they do not receive respectful care” (P6, Doctors).

“Women who don’t have much knowledge are not being explained properly” (P3, Nurses)

These patterns suggest that institutional care practices may reproduce existing social inequalities, affecting women’s right to equitable and non-discriminatory care, a core principle of SRHR.

Patient–provider interaction and behaviour

Several participants described how certain forms of verbal and physical control during labour were normalized within institutional culture, particularly when women were perceived as uncooperative. Such practices were sometimes justified as necessary to ensure compliance and positive clinical outcomes.

Everyone knows labour is painful, but despite our explanation, they become uncooperative. So, it is justified to scold or hit them to bring a better outcome for both mother and child (P2, Doctors).

These narratives reflect how power dynamics operate within clinical settings, where authority is maintained through control over women’s behaviour, potentially compromising women’s autonomy and bodily integrity, central to SRHR.

Neglect of women’s pain and autonomy

Many participants acknowledged that women’s pain and decision-making autonomy were frequently overlooked. Pain relief options were rarely communicated, and clinical decisions were often made without women’s active involvement.

“Sometimes, we ourselves tell them not to shout too much but we do not provide proper analgesia” (P9, Doctors).

This indicates a tendency to normalize women’s suffering during childbirth and limit their role in decision-making processes, thereby undermining women’s right to autonomy, informed choice, and appropriate pain management within the SRHR framework.

Part II: staff reflections on forum play in promoting respectful maternity care

In the second half of the discussion, the participants were asked to describe their reflection on the Forum Play workshop in promoting RMC. Under the staff’s reflection on the Forum Play workshop, there are two categories and five subcategories which are described below, illustrated with quotes.

Category 3: personal and professional transformation through forum play

This category was reported by most participants, indicating that the Forum Play workshop created space for reflection, dialogue, and reconsideration of everyday practices.

Self-reflection and behavioural change

Most participants described how engaging in role play and interactive exercises enabled them to reflect on their own behaviour and recognize previously normalized practices. Participants acknowledged their own roles in contributing to disrespect and expressed a willingness to change.

“Forum Play is helpful for us to improve our own behavior ourselves. The role play helped us to realize our weaknesses” (P10, Nurses).

This process of reflection aligns with principles of Pedagogy of the Oppressed, where critical awareness emerges through dialogue and reflection on lived experiences. By re-enacting real-life situations, participants were able to examine their actions from new perspectives.

Empathy development and perspective-taking

Many participants emphasized that Forum Play helped them better understand women’s experiences during labour. By stepping into different roles, they developed empathy and became more aware of how their words and actions affect patients.

“Forum Play helped us to be empathetic, and we came to know everyone’s perspective” (P5, Doctors).

This reflects the core approach of Theatre of the Oppressed, where participants move from passive observers to active “spect-actors,” engaging with and transforming social realities through experiential learning.

Awareness of respectful maternity care

Participants described an increased awareness of RMC and recognized gaps in their previous knowledge and practice. This shift was reflected in their acknowledgement of the importance of communication, dignity, and emotional support.

“I think we are shifting the era of safe motherhood towards respectful maternity care. This shift is a very good approach” (P10, Doctors).

The workshop thus facilitated a transition from routine, task-oriented care toward a more reflective and human-centered understanding of care.

Category 4: acceptance and institutional feasibility of forum play

This category reflects participants’ views on the acceptability, usefulness, and potential scalability of the intervention.

Experiential and participatory learning approach

Most participants described Forum Play as an engaging and effective learning method compared to conventional lecture-based training. The interactive format encouraged participation, discussion, and deeper understanding.

“We always focus on conferences and theoretical things. This approach is more humanizing” (P5, Doctors).

All the participants’ reflections on the Forum Play workshop were very promising. They found the Forum Play a very acceptable method of intervention. The interactive and participatory nature of the sessions kept learners actively involved, making the overall learning process more impactful and relevant to their work.

“Forum Play is very much acceptable because the workshop was based on real incidents. The Forum Play workshop helps us stay alert, even when we tend to forget our duties” (P5, Admin staff).

Participants highlighted that learning through enactment and dialogue made the content more relatable and memorable.

Institutionalization and system-wide application

Most participants expressed strong support for integrating Forum Play into routine training and extending it across departments and institutions. They emphasized the importance of involving all categories of staff and conducting such workshops regularly to ensure widespread training and sensitization.

“Forum Play should be practiced in every hospital everywhere” (P5, Doctors).

However, some participants also acknowledged challenges related to feasibility in routine clinical settings. Time constraints, high workload, and limited institutional support were perceived as significant barriers to regular implementation. This highlights that while Forum Play is widely accepted, its successful institutionalization depends on adequate organizational commitment.

“It is hard to explain feasibility because case to case scenario is different. I don’t see feasibility clearly, but it is acceptable” (P10, Doctors).

“Forum Play should be incorporated in hospital policy and carried out regularly” (P7, Nurses)

These findings suggest that Forum Play is widely perceived as acceptable, while its feasibility remains uncertain and dependent on adequate organizational commitment.

Discussion

Disrespect and abuse during facility-based childbirth remain a major concern in Nepal, reflecting broader structural and sociocultural factors within maternity care [5, 16]. While participants described multiple forms of disrespect and abuse, their narratives indicate that such practices are often normalized in routine care. Behaviour like shouting at or hitting women during labour sometimes justified as necessary to ensure favourable outcomes highlight the tension between biomedical priorities and women’s rights. This illustrates a paternalistic model of care, in which providers place clinical outcomes above women’s autonomy and dignity. Overall, these findings suggest that disrespect and abuse are not merely individual actions but are deeply embedded in institutional cultures and hierarchical power structures [32].

The tendency of providers to justify coercive practices aligns with findings from Ghana [33] and Nigeria [34, 35], where similar behaviors were reported and often driven by a strong sense of responsibility for maternal and neonatal outcomes. This pattern may reflect the shared challenges of resource-constrained settings, including high workloads and limited resources, which increase pressure to maintain control during labour. In contrast, studies from high-income countries such as Sweden describe abusive practices as largely unintentional, linked more to systemic and organizational constraints than to explicit justification [36]. These differences suggest that while structural pressures exist across contexts, the ways in which providers interpret and rationalize their actions are shaped by sociocultural norms, accountability systems, and professional expectations. In Nepal, hierarchical provider-patient relationships and limited mechanisms for patient feedback may further reinforce the acceptance of such behaviour.

Participants often attributed disrespect and abuse to systemic challenges, such as inadequate infrastructure, heavy workloads, and stressful working conditions, which aligns with findings from studies in Ethiopia [37] and Kenya [38]. From a systems perspective, these structural constraints influence provider behaviour and can limit the delivery of empathetic, patient-centered care. However, framing abuse primarily as unintentional risks minimizing accountability and overlooking the ethical dimensions of care. This underscores the need for interventions that address both systemic barriers and provider attitudes, ensuring that resource limitations are not used to justify compromises in RMC [3].

A key contribution of this study is its examination of Forum Play as an intervention to promote RMC. Participants found the method engaging and practical, but its value lies in its capacity to support experiential learning and behavioural reflection. Through role-play, providers can enact real-life scenarios, explore alternative responses, and critically reflect on their own practices. This process appears to foster both cognitive and emotional shifts, including increased empathy, heightened awareness of patient experiences, and recognition of underlying power dynamics. These mechanisms align with reflective learning processes, in which developing critical self-awareness is a crucial step toward meaningful behavioural change [28, 39]. By offering a safe space to rehearse interactions, Forum Play may help bridge the gap between knowledge and practice.

These findings align with studies from Sri Lanka, where Forum Play has also been used to address abuse in healthcare, though important contextual differences exist. In the Sri Lankan context, Forum Play increased providers’ awareness of obstetric violence and encouraged reflection on routine practices. Participants, like those in this study, appreciated its participatory approach and the opportunity to simulate real clinical scenarios. However, the Sri Lankan studies also pointed to structural limitations, such as weak systems for reporting abuse and safeguarding patient rights, which constrained sustained behavioural change [22, 23]. Similar challenges exist in Nepal, where systemic constraints and hierarchical institutional cultures may limit the effectiveness of behavioural interventions unless they are implemented alongside broader institutional support and training.

These findings can also be understood through the lenses of SRHR, Pedagogy of the Oppressed, and Theatre of the Oppressed. From a SRHR perspective, practices such as non-consented care, verbal and physical abuse, and lack of privacy constitute violations of women’s rights to dignity and autonomy [27]. Yet their normalization highlights a gap between a? right-based framework and everyday clinical practice. Pedagogy of the Oppressed helps explain how such practices persist within unequal power relations, where providers hold authority and women have limited agency [28]. In this context, Forum Play, grounded in Theatre of the Oppressed, offers a participatory space for dialogue, reflection, and action [25]. Through this process, providers can critically examine their own behaviour and explore alternative, respectful practices, supporting reflection that is directly linked to action.

This study also sheds light on the feasibility and acceptability of Forum Play within the Nepali healthcare context. Participants’ largely positive responses suggest that the approach is both culturally acceptable and adaptable. Its participatory, low-resource design makes it well-suited for resource-constrained settings, and involving administrative staff highlights its potential to foster shared understanding across different institutional roles. However, several challenges need to be considered. Time constraints, staff shortages, and competing clinical priorities may limit consistent participation, while differences in baseline awareness particularly among non-clinical staff could affect engagement. Sustainability and scalability are key considerations for broader implementation. Although participants recommended wider adoption, scaling up would require investment in facilitator training, standardization, and integration into existing health system structures. Without institutional support and alignment with ongoing quality improvement initiatives, the impact of such interventions may remain limited to short-term, individual-level changes.

Overall, addressing disrespect and abuse in maternity care requires a comprehensive approach that combines structural improvements with efforts to influence provider attitudes and behaviour. Forum Play appears to be a promising, contextually relevant approach for promoting reflective learning and respectful care. However, its effectiveness will depend on sustained implementation, supportive organizational environments, and alignment with broader efforts to uphold RMC and SRHR principles in everyday practice.

Measures to maintain trustworthiness

To ensure the rigor of our findings, we applied the four criteria of trustworthiness: credibility, transferability, dependability, and confirmability [30]. Credibility was achieved by collecting data from different staff groups and including rich, verbatim quotes. Focus group discussions were conducted immediately after workshops to capture participants’ reflections accurately. Transferability was supported by describing the study setting, sample, inclusion criteria, data collection process, and the Forum Play intervention in detail. Dependability was strengthened by organizing data into categories and subcategories and keeping a clear record of all coding and analysis steps. Confirmability was maintained by grounding findings in participants’ own words, developing categories from the data, and involving all authors in analysis to reduce bias.

Strengths, limitations and recommendations

Most of the previous studies related to RMC were conducted outside of Nepal and have stressed the need for behaviour change interventions to reduce disrespect and abuse in maternity care. No previous qualitative and interventional studies on RMC have been found in Nepal. Involving administrative staff in the workshop is an innovative experiment which may be helpful to address the structural barriers in the hospital. However, an experienced drama pedagogue is required for the proper execution of the Forum Play workshop. Thus, some of the participants were not sure about the feasibility of Forum Play.

Besides the single-site study, the small sample size with purposive sampling limits the generalizability of the findings. Furthermore, the largely positive feedback reported may reflect social desirability bias or hierarchical dynamics within group discussions. Resistance to behavioural change is expected, especially when interventions challenge long-standing norms and professional identities. While this study captures participants’ perceptions, it did not assess changes in actual behaviour or patient outcomes. Therefore, additional workshops involving a larger number of participants and longer follow-up focusing behavioral changes are needed to better evaluate the impact of the Forum Play intervention.

Conclusions

Based on participants’ experiences and reflections, Forum Play was seen as an acceptable approach for addressing disrespect and abuse during labour and childbirth. Hospital staff engaged actively in the workshops and considered the method relevant and useful for reflecting on their practices and promoting RMC. Some participants, however, expressed uncertainty about its feasibility in routine clinical settings, citing challenges such as time constraints, heavy workloads, and limited institutional support. This indicates that while the intervention is acceptable, its successful implementation depends on sufficient institutional commitment, including dedicated time, training, and managerial backing. In addition, efforts to strengthen providers’ practices and raise women’s awareness of their rights to RMC remain essential for reducing disrespect and abuse.

Abbreviations

RMC

Respectful maternity care

SRHR

Sexual and reproductive health and rights

Authors’ contributions

NP, KS, PD and SKJ contributed to conceptualization and research study design. AJ led the intervention sessions. NP, and PD collected data by focus group discussion. NP, KS and PD analysed and interpreted data. NP drafted the initial manuscript. AJ contributed to review and finalization of intervention section of methodology part. KS and PD contributed to critical review and finalization of the manuscript. All the authors read and approved the final manuscript.

Funding

This study was partially funded by the University Grants Commission Nepal (UGC-Nepal) under the PhD fellowship grants and Linnaeus University, Sweden.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

We followed the thical principles in accordance with the standard of Helsinki declaration to conduct this study. Ethical approval was obtained from the institutional review committee of the hospital where the pilot intervention was conducted (Ref. 29092023/01). Written informed consent from the participants was taken prior to the data collection. All the focus group discussions were audio recorded with the permission of participants. Considering the sensitivity of the issue, the name of the hospital has not been disclosed anywhere.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.