Main Points

• Respectful maternity care (RMC) is a well-described, rational approach for improving person-centered and equitable intrapartum and postpartum care, but it lacks a standard definition, clear measurement method, or evidence of effectiveness.
• Two types of RMC frameworks described in the literature based on either (1) Disrespect and Abuse or (2) Rights-Based, have overlapping themes with components that reflect efforts to implement metrics to eliminate practices identified as disrespect or abuse, and initiatives to work toward healthcare systems and settings that focus on respectful care. Common themes include: freedom from abuse, consent, privacy, dignity, communication, safety, and justice.
• Based on analyses of psychometric properties presented in 24 validation studies, 10 tools were considered to have fair or good overall validity and two tools had poor overall validity.
• RMC tools have not been subject to widespread testing and no single validated tool stands out as the best measure of RMC. However, the intrapartum version of the Mother’s Autonomy in Decision-Making (MADM) and Mothers On Respect index (MORi) tools, and the Childbirth Options, Information, and Person-Centered Explanation (CHOICES) index for measuring RMC demonstrate good overall validity and are most relevant to U.S. populations. The Revised Childbirth Experience Questionnaire (CEQ-2) also demonstrated good overall validity for measuring childbirth experiences and includes some RMC components.
• Components of tools identified as having good validity to measure RMC incorporated themes of privacy, dignity, respect, autonomy, and communication or shared decision making. Teamwork and communication (among providers, staff, patients and families) was not specifically described as part of an RMC tool; however, shared decision making was framed as a way to improve communication between patients and providers and may facilitate teamwork and communication.
• One randomized controlled trial from Iran evaluated the effectiveness of an RMC intervention and demonstrated lower rates of postpartum depression for RMC compared with controls (20% vs. 50%, p=0.001).
• No trials from the United States or settings applicable to clinical practice in the United States evaluated the effectiveness of RMC for any health, utilization, or patient reported outcome.
• Alongside the urgent need to implement RMC, goals for RMC must include further testing of reliable performance measures and consensus around a clear definition to help standardize care delivery to ensure RMC for all who are pregnant or postpartum.

Background and Purpose

Severe maternal morbidity and death is worse in the United States than in all comparable countries, with the greatest impact on Black women. Emerging research suggests disrespectful care during childbirth contributes to this problem. This systematic review synthesizes research for defining and measuring RMC and identifying its absence (also described as disrespect or abuse during childbirth). It also examines the effectiveness of strategies for implementing RMC on health outcomes, particularly for populations at risk for health disparities. This effort is part of an initiative to improve person-centered and equitable care for birthing people and incorporate pregnant and postpartum individuals and their identified support networks as part of the multidisciplinary care team. This review is intended to be useful to clinicians, patients, and policy makers, and may help inform a clearer understanding of target metrics for evaluation of RMC, including the impact on maternal health outcomes and patient experiences.

Methods

This review follows standard methods for systematic reviews¹ based on methods developed by the Agency for Healthcare Research and Quality for effectiveness reviews. The protocol was registered with PROSPERO (CRD394769). Searches were conducted in Ovid MEDLINE^®, CINAHL^®, Embase^®, and Cochrane CENTRAL databases from inception to November 2022 and SocINDEX to July 2023 and were supplemented by manual review of reference lists and a Federal Register Notice. In collaboration with Federal partners, Key Informants, and a Technical Expert Panel, investigators developed pre-established eligibility criteria defined by populations, interventions, comparators, outcomes, and setting (PICOTS). The population included pregnant and postpartum adolescents and adults for all questions using gendered (e.g., women) and nongendered terms (e.g., person, individual). Methods are discussed in detail in the full report and in Appendix A.

Results

Searches of electronic databases and reference lists yielded 4,043 references. After dual review of titles and abstracts, 443 papers were selected for full-text review. Thirty-seven studies were included across all Key Questions (KQs), including the Contextual Question (CQ). Twenty-four validation studies (3 observational studies, 21 cross-sectional studies) evaluated 12 tools for measuring RMC, including studies validating tools in other languages. For KQ2, one RCT from Iran evaluated RMC effectiveness on maternal clinical outcomes; there were no effectiveness trials from countries relevant to clinical practice in the United States for any clinical outcome. For KQ3 and 4, there were no studies of RMC effectiveness on infant health outcomes and no studies evaluating the effectiveness of RMC implementation strategies. For the CQ, we identified 12 studies as the original source documents that described 12 frameworks to characterize RMC. Although not formally included as evidence, 77 cross-sectional studies applying the 12 frameworks in specific countries and settings were included in CQ tables; therefore, these studies were not listed as excluded articles. There was no data on harms of RMC, but frameworks identified in the literature clearly defined related concepts of disrespect and abuse.

Strengths and Limitations

Many studies included in our review were from cross-sectional surveys from low- and middle-income countries (LMIC) to inform the CQ to describe RMC, or apply various measures of disrespect and abuse or RMC, but were based only on prevalence of women’s experiences. There is not yet a definitive framework or consensus around a definition for RMC. Although no single tool emerged as the best measure of RMC, this report provides evidence on the available validated tools to measure the receipt and delivery of RMC and assessment of those that are most relevant to U.S. populations.

There was a lack of evidence on the effectiveness of RMC on clinical, utilization, or patient reported outcomes. Few studies specifically addressed professional training, or specific procedures or policies to inform strategies around teamwork or communication. Most limitations of the evidence base were related to the lack of relevant studies to evaluate interventions of RMC effectiveness, the relative weakness of study designs used in this field, which were mostly cross-sectional, the rigor with which the studies were conducted, and the incomplete reporting of key outcomes. This review was limited to the intrapartum and postpartum periods, and some of the measures were not specific to this time period only. No studies evaluated the effectiveness of RMC implementation strategies and how implementation affects health outcomes. No studies reported on factors related to health disparities or the potential harms of RMC.

Future Research Needs and Opportunities

In the United States, there is an increasing awareness of maternal health disparities and urgent calls for changes in healthcare delivery that improve safety, eliminate racism, and improve health outcomes for all who are pregnant and postpartum.^2,3 The literature in this review suggested agreement that RMC is a fundamental tenet of obstetric care that should be promoted. This aligns with wider arguments recognizing the inalienable nature of key human rights and freedoms. But unlike many literature review and synthesis topics, the concept of respectful maternity care is still being defined, a critical step towards wider outcomes testing. This report summarizes essential components of RMC based on identified frameworks and highlights useful examples of tools to measure RMC by identifying which tools demonstrate methodologically sound design and validity. This information should serve as a guide to (1) define RMC, (2) determine an appropriate metric, and (3) promote research to evaluate whether widespread implementation improves health outcomes. When literature review and synthesis does not result in strong evidence about how a particular intervention impacts outcomes, it may be common to conclude that standard care should not be challenged or modified. We caution against this conclusion. Instead, we recommend that readers focus on this review’s findings revealing longstanding and multidisciplinary research on the concept of RMC to catalyze wider instrument development and promote careful consideration of future work to define and test the impact of strategies to deliver RMC.

Research is needed to evaluate interventions for promoting RMC not addressed by existing studies, including effectiveness of RMC implementation strategies and how RMC affects health, utilization, or patient reported outcomes. Future effectiveness trials should include patients with diverse backgrounds, including those who are at risk for experiencing discrimination due to socioeconomic factors, rural location, or geographic isolation; and from other groups at risk for experiencing health disparities based on race, ethnicity, disabilities, or trauma. Before widespread implementation of tools to measure RMC, further testing of current measures and a clear definition to help standardize care delivery may help assure RMC for all birthing people. To further operationalize respectful maternity care, qualitative research would help elucidate perspectives of those who are pregnant or postpartum, companions, and healthcare team members on respectful maternity care and its components.

Based on this review’s findings and input from experts, we proposed a clear definition (Box A) to help bridge the gap between RMC conceptual models, theoretical frameworks, and validated measures and to provide a practical paradigm for the delivery and receipt of peripartum care through a rights- and reproductive justice-based framework. This definition incorporates widely accepted frameworks to outline critical components for application of reliable methods to measure RMC.

Implications and Conclusions

RMC has been described extensively throughout the literature and has become recognized in the obstetric community as a strategy to reduce maternal health disparities, but consensus around a common definition is needed. Our proposed definition incorporates expert input with an extensive evaluation of the literature to include standard elements of respectful care for informing perinatal safety and culture, including: freedom from abuse and violence, consent, privacy, communication and shared decision making, dignity and respect, safety, and justice. Two types of RMC frameworks have overlapping components and themes that inform the understanding of RMC. Validated tools to measure RMC demonstrated fair to good overall validity, but have been subject to limited evaluation. A reliable metric informed by a standard definition could lead to further evaluation and implementation in U.S. settings. Evidence is currently lacking on the effectiveness of strategies to implement RMC to improve any maternal or infant health outcome.

References

1.

Agency for Healthcare Research and Quality. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Effective Health Care Program; February 23, 2018 2018. https:​//effectivehealthcare​.ahrq.gov/products​/collections/cer-methods-guide. [PubMed: 21433403]

2.

Alliance for Innovation on Maternal Health. Obstetric Hemorrhage. ACOG; 2022. https://saferbirth​.org​/psbs/obstetric-hemorrhage/. Accessed July 11, 2022.

3.

Alliance for Innovation on Maternal Health Care. Severe Hypertension in Pregnancy. ACOG; 2022. https://saferbirth​.org​/psbs/severe-hypertension-in-pregnancy/. Accessed July 11, 2022.