Quality intrapartum care expectations and experiences of women in sub- Saharan African Low and Low Middle-Income Countries: A qualitative meta- synthesis

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Ahmed, Abela Mahimbo, Angela Dawson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2019687/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jan, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Women-centred maternity care is respectful and responsive to women’s needs, values, and preferences. Women’s views and expectations regarding the quality of health services during pregnancy and childbirth vary across settings. Despite the need for context-relevant evidence, to our knowledge, no reviews focus on what women in sub-Saharan African Low and Low Middle-Income Countries (LLMICs) regard as quality intrapartum care that can inform quality guidelines in countries. Methods: We undertook a qualitative meta-synthesis using a two-stage thematic synthesis to identify the experiences and expectations of women in sub-Saharan African LLMICs with quality intrapartum care. Following a priori protocol, we searched eight databases for primary articles using keywords. We used Covidence to collate citations, remove duplicates, and screen articles using a priori set inclusion and exclusion criteria. Two authors independently screened first the title and abstracts, and the full texts of the papers. Using a data extraction excel sheet, we extracted first-order constructs and second-order relevant to review objectives. The WHO framework for a positive childbirth experience underpinned data analysis. Results Of the 7197 identified citations, 30 articles were included in this review. Women’s needs during the intrapartum period resonate with what women want globally, however, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. Women received sub-quality intrapartum care and global standards for women-centred care were often compromised. They were mistreated verbally and physically. Women experienced poor communication with their care providers and non-consensual care and were rarely involved in decisions concerning their care. Women were denied the companion of choice due to cultural and structural factors. Conclusion To improve care seeking and satisfaction with health services, women-centred care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Research is needed to set minimum indicators for women-centred outcomes for low-resource settings along with actionable strategies to enhance the quality of maternity care based on women’s needs and preferences. Women-centred care intrapartum care quality of care experiences expectations sub-Sahara Africa Low and Low Middle-Income Countries Figures Figure 1 Introduction Many countries have made significant progress toward decreasing maternal mortality; however, much work is required to reach the Sustainable Development Goal (SDG) global target of less than 70 per 100,000 live births by 2030 ( 1 ). Eighty percent of maternal deaths are preventable ( 2 ). An estimated 295,000 maternal deaths occurred globally in 2017 due to pregnancy and delivery-related causes ( 1 ). Despite the substantial progress of countries toward increasing access to maternity services, this has not been reflected in decreasing maternal mortality and morbidity as much as expected ( 3 ). This mismatch between health outcomes and access to services is attributed to the poor quality of services provided to women during pregnancy, childbirth, and postpartum periods ( 3 , 4 ). The reduction in maternal and neonatal deaths requires a rapid improvement in the quality and coverage of health services in low and low-middle-income countries (LLMICs). A fundamental strategy for reducing maternal mortality is increasing access to skilled attendance during childbirth. Skilled birth attendance involves trained, competent, and motivated health workers delivering evidence-based interventions in an enabling environment ( 5 ). A skilled birth attendant (SBA) is a care provider, often a nurse, a midwife, or a doctor, trained to manage normal delivery, detect danger signs, and refer women in a timely manner to receive specialized care ( 6 ). An enabling environment involves the presence of essential medicines and equipment, alongside a functioning referral system ( 6 ). Globally, around 80% of births are assisted by a skilled attendant ( 7 ). However, the coverage of skilled birth attendance varies within countries and across regions. Seventy-seven percent of births are attended by an SBA in Central and Southern Asia while around 59% of births are attended by a skilled provider in Sub-Saharan Africa ( 7 ). While women are encouraged to give birth to their babies with the assistance of a skilled provider in a health facility, facilities may be understaffed, overcrowded, and provide low-quality services ( 8 ). A systematic review of factors affecting the provision of maternal services in LLMICs has shown that lack of supportive supervision, understaffing, and high workloads of care providers contribute to the decreased quality of services ( 9 ). Moreover, low salaries and poor working conditions also contribute to provider stress and performance alongside a lack of equipment and medicines ( 9 ). The initiatives to increase the coverage of skilled birth attendance must go hand in hand with strategies to guarantee that women receive quality services before, during, and after childbirth. Women-centred maternity care is defined as respectful care that is responsive to women’s needs, values, and preferences ( 10 , 11 ). In 2018, the World Health Organization (WHO) published a set of recommendations for a positive experience during pregnancy and childbirth as part of their support for global high-quality antenatal, delivery, and postnatal care ( 12 ). These recommendations embrace the optimization of the health and well-being of women and their babies through a women-centred approach rather than a focus on the prevention of mortality and morbidity during pregnancy. In this model, the WHO describes intrapartum care as A platform to provide pregnant women with respectful, individualized, woman-centred, and effective clinical and non-clinical practices to optimize birth outcomes for the woman and her baby, by skilled healthcare providers in a well-functioning healthcare system ( 12 ). A systematic review explored women’s needs during childbirth globally in 2018, however, the majority of studies included in this review were conducted in high and middle-income countries, and only included three studies were from African Sub-Saharan (SSA) LLMICs ( 13 ). To our knowledge, no systematic review has been published that focuses on the expectations of women in SSA LLMICs and what women regard as quality care during childbirth. The perspectives of women on what matters to them will support the evidence base for the contextualization and operationalization of WHO guidelines on intrapartum care for a positive childbirth experience in SSA LLMICs. The findings can inform the planning, implementation, and appraisal of maternity services which includes the development of women-centred policies and service guidelines. Methods This qualitative meta-synthesis was conducted following a priori protocol registered on The International Prospective Register of Systematic Reviews (PROSPERO) (Ref. CRD42021292682). Qualitative meta-synthesis is a structured approach to summarizing, collating, and interpreting primary qualitative data and the interpretations reported in peer-reviewed articles ( 14 ). A preliminary scoping was done prior to the development of the protocol to refine the review question, determine the feasibility of the review and the nature of current evidence, and decide the method of synthesis. The review question was “what are the intrapartum midwifery care experiences and expectations of women of quality care in SSA LLMICs”. We designed and reported this review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( 15 ). Search strategy and study selection: We developed a search strategy for qualitative and mixed-methods peer-reviewed articles published between 2011 and 2021. The electronic search was run using eight databases including MEDLINE (Ovid), Global Health, EMBASE (Ovid), CINAHL Plus, Web of Science, SCOPUS, Africa Journals Online (AJOL), and the Maternity and Infant Care Index. The search terms included three main concepts; expectations or satisfaction of women, quality intrapartum care, and eligible geographical scope and countries. Please refer to Supplementary file 1 for a sample of the search strategies used for MEDLINE (Ovid). All searches were conducted from the 13th of December 2021 to the 16th of December 2021. All citations retrieved from electronic searches in databases were imported into a web-based software platform, Covidence, which is used for the management of collation of citations, removal of duplicates, and screening processes. The first author carried out this phase. Two authors independently screened the title and abstracts of identified citations using Covidence. Furthermore, two authors per citation screened full texts for eligibility using inclusion and exclusion criteria (Supplementary file 2) for the final included studies selected (n = 30) (Fig. 1 ). Disagreements during screening were resolved by discussions of the research team and having a third opinion. The searches of the targeted databases yielded 7197 citations. After the screening of title and abstracts, full texts of potential eligible 43 articles were retrieved. After exclusions, 30 articles were included in this systematic review (Fig. 1 ). (Fig. 1 comes here) Quality appraisal Two reviewers independently appraised included studies using a quality appraisal checklist. We used the Critical Appraisal Skills Programme (CASP) checklist to assess the quality of peer-reviewed qualitative studies (Supplementary files 3 and 4) ( 16 ). Whereas, mixed methods peer-reviewed articles, we used the Mixed Methods Appraisal Tool (MMAT) (Supplementary file 5) ( 17 ). Disagreements during quality appraisal were resolved by discussion of the team. Quality appraisal tools were used to highlight the strengths and weaknesses of studies to assist in the interpretation of the findings. No studies were excluded during the quality appraisal process. Data extraction, analysis, and synthesis Data that included first-order constructs i.e. women’s views and accounts and second-order constructs i.e. authors’ interpretations relevant to review objectives, were extracted and summarized by the first author using a data extraction excel sheet. The data extraction sheet was developed by the first author for the purpose of this review and it was piloted in the extraction of data from three articles prior to use. The variables included characteristics of the articles including the aims, number and demographic features of the study population, the study context, responsiveness, dignified care and respect, access to emotional support during childbirth, patient-provider communication and engagement, continuity of care, pain management, and responsive healthcare providers and physical environment during childbirth. The sheet included a description of what elements were included in each theme for consistency. Based on the purpose of the review and the heterogeneous nature of the qualitative evidence, we conducted a thematic synthesis in two stages ( 14 ). The first stage included data reduction and thematic extraction of primary study findings ( 18 ) based on the WHO intrapartum care model for a positive childbirth experience, ( 12 , 19 ) i.e. within-study analysis. While the second stage entailed a cross-studies thematic synthesis using a deductive and inductive approach ( 14 , 18 ). Results This qualitative meta-synthesis included 30 articles from nine African Sub-Saharan Low and Low-Middle Income Countries, including Ethiopia (n = 6), Ghana (n = 3), Guinea (n = 1), Kenya (n = 4), Malawi (n = 6), Nigeria (n = 3), Tanzania (n = 2), Uganda (n = 3), Tanzania and Zambia (n = 1), and Uganda and Nigeria (n = 1). The characteristics of the articles are summarized in Table 1 . Most studies explored the experiences of women and their views concerning the quality of intrapartum care (n = 17). However, some studies included women’s partners as well (n = 3), different categories of healthcare providers, community health workers, and community leaders (n = 10). Table 1 Characteristics of included articles # Reference Country/ies Method Aim Eligible study population 1 Afulani et al. (2017) Kenya Qualitative study Focus group discussions To examine women’s facility-based childbirth experiences in a rural county in Kenya and aspects of care that contribute to a positive or negative birth experience. 58 women (postnatal) 2 Kumbani et al. (2012) Malawi Qualitative study in depth interviews Women’s perceptions on perinatal care among the women delivered at a district hospital. 14 women (postnatal) 3 Jolly et. al (2019) Malawi Qualitative study in-depth interviews and key-informant interviews Women’s perceptions regarding respectful maternity care and the knowledge and understanding of the seven domains of the RMC Charter among healthcare providers 64 women (recruited from antenatal, intrapartum and postnatal clinics) 4 O’Donnell et al. (2014) Malawi Qualitative study in depth interviews Perceptions of women and HCPs of maternity care in a rural setting in Malawi. 33 women (postnatal) 5 Maya et. al. (2018) Ghana Exploratory qualitative study in depth interviews focus group discussions Women’s perspectives of mistreatment during facility-based childbirth in the Ghanaian context 110 women 6 Dalinjong et. al. (2018) Ghana Qualitative part of a bigger convergent mixed-methods study Focus group discussions In-depth interviews To assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities and to explore women and health providers’ views on privacy and satisfaction with quality of care women in postnatal period (number of women who participated in the FGD sessions is not provided) 7 Namujju et. al. (2018) Uganda Phenomenological qualitative study In-depth interviews and focus group discussions To describe the childbirth experiences and the perceived meanings among postnatal mothers to broaden the information base for appropriate intervention development and individualized care during childbirth 25 women (postnatal) 8 Afulani et al. (2018) Kenya Qualitative part of a bigger mixed methods study In-depth interviews and focus group discussions Prevalence and determinants of birth companionship, and women and providers’ perceptions of it in health facilities in a rural County in Western Kenya 58 women (postnatal) 9 Bohren et. al. (2017) Uganda and Nigeria Exploratory qualitative study in depth interviews focus group discussions To explore what “quality of care” means to childbearing women in Nigeria and Uganda, Postnatal women (number of women who participated in the FGD sessions is not provided) 10 Kyaddondo et. al. (2017) Uganda Formative qualitative study in depth interviews focus group discussions The experiences, expectations, and needs of urban Ugandan women in relation to good-quality facility childbirth. 85 women 11 Mehretie Adinew and Abera Assefa (2017) Ethiopia Exploratory qualitative study In-depth interviews and focus group discussions To explore why some women with previous experience of facility-based delivery care gave birth at home for their most recent child by in-depth understanding of women’s previous facility-based delivery experience, perspective towards health facilities and service providers with regard to delivery services 88 women 12 McMahon et. al. (2014) Tanzania Qualitative study (grounded theory) in depth interviews To understand how rural Tanzanian women and their male partners describe disrespect and abuse experienced during childbirth in facilities and how they respond to abuse in the short or long-term 49 women 13 Dzomeku et.al. (2017) Ghana Exploratory qualitative research In-depth interviews To explore women's experiences with childbirth care in Kumasi, Ghana 56 women (attending antenatal or postnatal care) 14 Oluoch-Aridi et. al. (2018) Kenya Qualitative study in depth interviews and focus group discussions The experiences and perceptions of women and healthcare workers regarding mistreatment during childbirth 46 women 15 Kaye et. al. (2015) Uganda Phenomenological qualitative study In-depth interviews To gain a deeper understanding of mothers’ perspectives on quality of care (the structure, process and outcome of intrapartum care) particularly during duty handovers. 30 women (postnatal) 16 Madula et. al. (2018) Malawi Qualitative study in depth interviews To examine the nature of communication in the maternity ward, and to identify facilitators and barriers to healthcare provider-patient communication 30 women (recruited from antenatal or postnatal clinic) 17 Mselle et. al. (2019) Tanzania Qualitative study in depth interviews and focus group discussions The experiences of mothers and fathers in relation to mistreatment during childbirth in Tanzania. 13 women (postnatal) 18 Malachi et. al. (2016) Kenya Qualitative part of a bigger mixed methods study In-depth interviews and key informant interviews To evaluate the institutional factors influencing women’s perception of quality intrapartum care. women in postnatal period (number of women participated in the FGD session is not provided) 19 Debela et. al. (2021) Ethiopia Qualitative part of a bigger mixed methods study In-depth interviews To explore underlying determinants of maternal satisfaction towards institutional delivery care among mothers who gave birth in public health facilities 36 women 20 Burrowes et. al. (2017) Ethiopia Qualitative study In-depth interviews Women’s experiences of midwifery care during labor and to explore midwives’ understandings of patients’ rights and patient-centered care and their experiences with patient abuse and disrespect; 23 women 21 Bohren et. al. (2017) Nigeria Qualitative study In-depth interviews and focus group discussions To explore women and providers’ experiences and perceptions of mistreatment during childbirth 75 women 22 Balde et. al. (2017) Guinea Qualitative study In-depth interviews and focus group discussions To explore the perceptions and experiences of women and HCPs of mistreatment during childbirth 109 women 23 Jiru and Sendo (2021) Ethiopia Exploratory qualitative study In-depth interviews To explore women’ and midwives’ perceptions of compassionate and respectful care during facility-based delivery 12 women (postnatal) 24 Asrese (2020) Ethiopia Qualitative part of a bigger mixed methods study In-depth interviews To assess the quality of intrapartum care experienced by mothers at health centers 25 women (postnatal) 25 Lavender et. al. (2021) Tanzania and Zambia Qualitative study (grounded theory) In-depth interviews Exploring care through multiple lenses enabling a more comprehensive understanding of relational contributors to experiences through examining the intrapartum experiences of women, partners, different health-providers and key stakeholders 48 women (postnatal) 26 Ojelade et. al. (2017) Nigeria Qualitative study in depth interviews and focus group discussions Women’s needs for communication and emotional support during facility- based childbirth 77 women 27 Mgawadere et. al. (2019) Malawi qualitative study Focus group discussions and key-informant interviews To explore women’s and healthcare provider’s perspectives of what quality of care during childbirth means to them 134 women (postpartum) 28 Orpin et. al. (2018) Nigeria Phenomenological qualitative study Focus group discussions To explore the women experiences of disrespect and abuse during pregnancy, childbirth, and in the postnatal period and its impact on the future use of health facilities for maternity care. 32 women (postnatal) 29 Machira and Palamuleni (2018) Malawi Qualitative study Focus group discussions Women’s perspectives on the quality of maternal health care services in Malawi 58 women 30 Gebremichael et. al. (2018) Ethiopia Phenomenological qualitative study Focus group discussions Women’s experience of disrespect and abuse during childbirth at health facilities 62 women We present the women’s experiences and expectations regarding quality intrapartum care categorized according to the themes; dignified care and respect, communication and meaningful engagement in care, access to emotional support during childbirth, continuity of care, pain management, and responsiveness of health facility setting and health services. Our findings indicate that women in Sub-Saharan LLMICs need clinical and non-clinical staff to treat them with respect and in a non-discriminatory and non-abusive manner. In addition, women wanted to feel welcomed throughout their stay in health facilities. Women described the need to be meaningfully involved in their care and to have open and effective communication with their care providers which helped them prepare for labour. Women also wanted to be emotionally and physically supported by care providers and their birth companions. The findings show that women expect to receive timely care and be monitored closely in a safe environment at health facilities. (Table 1 ) Dignified care and respect Women demanded to be treated with respect during childbirth and expected healthcare providers to be non-judgmental ( 20 ), kind ( 21 ), and respectful ( 22 ). For a positive childbirth experience, women described needing respectful and dignified intrapartum care while maintaining their privacy and wanting to be meaningfully engaged in their care ( 23 ). In addition to health care providers (HCPs), the positive attitude of non-clinical staff, such as cleaners and security guards also contributed to a positive experience ( 22 ). Women described dignified care that involved physical support ( 22 ). When I was in labor, a nurse brought me porridge for me to have energy during delivery of the baby. I saw that I was respected ( 21 ) Disrespectful care was also reported by women in LLMICs who were verbally and physically abused during childbirth and suffered discrimination as a result of their age, ethnicity, literacy level, and socioeconomic status ( 22 , 24 – 35 ). Respectful. The first thing which comes to my mind ... the client must be respected. Respected that is ... to receive care ... not (taking into account) age, worth, colour or religion ( 20 ). Verbal and physical abuse includes shouting, yelling, ridicule, judgmental remarks from healthcare providers, and slapping and whipping of women during childbirth. In few studies, however, women considered the abusive behaviour of healthcare providers as a normative behaviour ( 31 ) or they expected to be shouted at ( 21 , 25 ) or provided sociocultural and contextual justifications for their behaviour such as encouragement of women, stress, and poor working conditions ( 25 , 27 , 30 , 36 ). Women encounter discrimination as well based on their tribes, age, literacy level, and socioeconomic status ( 22 , 25 , 34 , 37 – 39 ). A study conducted in Zambia and Tanzania classified discrimination into two categories; direct and indirect, direct discrimination includes discriminatory incidents that happen to women during childbirth whereas indirect discrimination was defined as when women received poor quality of care caused by policies that are meant for everyone such as the assignment of professionals to central and referral facilities instead of rural areas ( 38 ). Studies showed that young girls giving birth or unmarried women received judgmental remarks from HCPs ( 25 , 34 ). Women demanded to be treated impartially without discrimination and considered being treated by non-judgmental HCPs as essential for a positive childbirth experience ( 20 ). Women in LLMICs also reported experiencing a lack of privacy during childbirth and unnecessary physical exposure due to contextual factors such as crowded wards and poor infrastructure at health facilities ( 20 , 22 , 23 , 36 , 38 , 40 , 41 ). Due to the lack of infrastructure and congestion of hospitals, it was hard to maintain the privacy of women in such context so it was not uncommon to have several women giving birth in the same room - so women need privacy during childbirth with curtains or cubicles ( 23 ) However, one study indicated that privacy was not a big concern for women in that context compared to not having care ( 20 ). In addition, women could not complain about the lack of privacy because they feared retribution from care providers ( 38 ). (Table 2 comes here) Table 2 Themes reported in primary articles Source Dignified care and respect Communication and meaningful engagement in care Access to emotional support during childbirth Continuity of care pain management Responsiveness Afulani et al.(2017) Importance of the positive attitude of staff for a positive childbirth experience Negative experiences related to dignified care and respect Negative experiences related to communication and engagement in care Women’s needs related to communication Significance of emotional and physical support from HCPs for a positive childbirth experience Negative experiences related to pain management Significance of physical environment in having a positive experience Women’s needs regarding responsiveness and physical environment Negative experiences related to responsiveness Kumbani et al. (2012) Positive and negative experiences related to dignified care and respect Negative experiences related to communication and engagement in care Negative experiences related to pain management Significance of feeling welcomed Negative experiences related to responsiveness Jolly et. al (2019) Expectations of women regarding respectful care Importance of non-judgmental HCPs for a positive childbirth experience Women’s ability to make informed decisions Women’s needs related to communication during childbirth Significance of support around the clock and timeliness of care O’Donnell et al. (2014) Negative experiences related to respectful care Negative experiences related to communication and engagement in care Positive experiences related to access to emotional support Significance of feeling welcomed and timeliness of care for positive experience Maya et. al. (2018) Negative experiences related to respectful care Expectations of women regarding respectful care Significance of feeling welcomed for positive experience Negative experiences related to responsiveness Dalinjong et. al. (2018) Negative experiences related to respectful care Positive experiences related to access to support Namujju et. al. (2018) Negative experiences related to respectful care Negative experiences related to communication and engagement in care Roles of birth companion in provision of support during labor Preferences of women regarding birth companions Perceptions of women related to labor pain Negative experiences related to pain management Negative experiences related to responsiveness Afulani et al. (2018) Reasons why women need a birth companion Positive and negative experiences related to birth companion Bohren et. al. (2017) Negative experiences related to respectful care Expectations of women regarding respectful care Expectations of women regarding communication Expectations of women related to access to emotional support Expectations of women regarding continuity of care Women’s needs regarding physical environment Kyaddondo et. al. (2017) Women expectations regarding respectful care Negative experiences related to respectful care Significance of communication for a positive childbirth experience Negative experiences related to communication and engagement in care Women’s needs related to emotional support during childbirth Expectations of women regarding continuity of care Women’s needs regarding physical environment Significance of feeling welcomed for a positive experience Mehretie Adinew and Abera Assefa (2017) Negative experiences related to respectful care Negative experiences related to communication and engagement in care Negative experiences related to access to support Negative experiences related to responsiveness McMahon et. al. (2014) Negative experiences related to respectful care Negative experiences related to responsiveness Dzomeku et.al. (2017) Negative experiences related to respectful care Negative experiences related to communication and engagement in care Positive experiences related to access to support Positive experiences related to responsiveness of staff Oluoch-Aridi et. al. (2018) Negative experiences related to respectful care Negative experiences related to access to support Negative experiences related to responsiveness Kaye et. al. (2015) Negative experiences related to communication and engagement in care Women expectations regarding continuity of care Negative experiences related to continuity of care Madula et. al. (2018) Negative experiences related to respectful care Negative experiences related to communication and engagement in care Positive experiences related to responsiveness of staff Mselle et. al. (2019) Positive and negative experiences related to respectful care Significance of effective communication for satisfaction with services Negative experiences related to communication and engagement in care Needs of women regarding birth companion and support from healthcare providers Negative experiences related to pain management Negative experiences related to responsiveness Malachi et. al. (2016) Negative experiences related to inadequate physical environment Debela et. al. (2021) Access to psychological support during labor Negative experiences related to responsiveness Burrowes et. al. (2017) Negative experiences related to respectful care Negative experiences related to access to support Preferences of women regarding birth companion Negative experiences related to continuity of care Negative experiences related to responsiveness Bohren et. al. (2017) Negative experiences related to respectful care Women perceived contributing factors of mistreatment Positive experiences related to access to support Balde et. al. (2017) Negative experiences related to respectful care Negative experiences related to responsiveness Jiru and Sendo (2021) Negative experiences related to respectful care Positive experiences related to access to support Asrese (2020) Negative experiences related to respectful care Negative experiences related to communication and engagement in care Positive and negative experiences related to access to support Negative experiences related to responsiveness Lavender et. al. (2021) Poor experiences were tolerated as long as their babies are fine Negative experiences related to respectful care Ojelade et. al. (2017) Significance of effective communication for a positive childbirth experience Needs of women related to access to support Negative experiences related to access to support Mgawadere et. al. (2019) Negative experiences related to respectful care Significance of effective communication for a positive childbirth experience Infrastructural factors behind denial of birth companion Negative experiences related to access to support Significance of feeling welcomed for positive experience Orpin et. al. (2018) Women perceived contributing factors of mistreatment Machira and Palamuleni (2018) Negative experiences related to respectful care Negative experiences related to access to support Negative experiences related to responsiveness Gebremichael et. al. (2018) Negative experiences related to respectful care Positive experiences related to access to support Negative experiences related to continuity of care Negative experiences related to pain management negative experiences related to Responsiveness Communication and meaningful engagement in care In half of the included studies, women described their experiences and expectations regarding communication with health providers and engagement in care. Women in LLMICs reported that open, effective, clear, two-way communication where HCPs used positive language and were able to ask questions as an important aspect of quality care and satisfaction with delivery services ( 20 , 22 , 23 , 27 , 36 , 42 , 43 ). A women stated “ Communication is very, very important...it is everything” ( 43 ). They appreciated it when HCPs sought their consent and gave them regular updates about their progress in labour ( 20 , 22 ) and they referred to having open communication as ‘friendship’ with care providers ( 36 ). They [healthcare providers] should continuously ask questions... ‘how do you feel,’ ‘how are you feeling now.’ It’s not supposed to just be the woman that will be telling them ‘please come check on me’...they [healthcare providers] should be continuously telling the woman ‘this is your condition,’ and educate them. ( 43 ) Women cited poor communication during childbirth ( 21 , 23 , 29 , 35 , 42 , 44 ) that included the inability to ask questions ( 39 , 41 ), HCPs not introducing themselves or not using women’s names ( 22 ), communication difficulties for women living with disability ( 39 ), and communication in languages other than their mother tongue ( 39 ). Women also spoke of a lack of information that made them feel unprepared and caused stress during the labour ( 36 ). In addition, communication gaps resulted in misinterpretation of providers’ motivations ( 23 ). Studies indicated that women were rarely involved in decision-making in LLMICs ( 26 , 32 , 33 , 35 , 42 , 44 ). For instance, women did not understand why care providers opted to use a specific management plan ( 33 , 35 , 44 ). In addition, women were not involved in choosing their delivery positions ( 42 ). “The midwives did not even engage me in any discussions over my childbirth process. They never told or asked me about anything” ( 33 ). Women in LLMICs wanted to be listened to and be meaningfully involved in decision-making in actions affecting their care such as preferred labour position, treatment options, and others ( 23 , 42 ). Access to emotional support during childbirth The experiences and expectations of women regarding emotional support through labour were detailed in the majority of studies. According to the voices of women in the papers included in this review, labour constituted an important and stressful occasion that substantiates emotional support throughout their stay at the health facilities. Women wanted to be cared for and encouraged to go through labour with a birth companion of their choice ( 22 , 23 , 35 , 36 , 43 , 45 , 46 ). Good quality of care is when you come to a health facility, you are received, they know what that moment means to you and that of your child and the kind of reception they give you as a mother that wants to deliver her child. They receive you warmly, encourage you. .. what matters most is that when you come into a health facility, there’s this confidence derived that assures one that she’s in good hands. ( 36 ) Women in LLMICs are accompanied by their mothers, sisters, mothers-in-law, husbands, and doula (a traditional birth attendant or an older woman from their communities) ( 23 , 35 , 45 ). Husbands in the majority of facilities where studies took place were not allowed inside the labour room ( 23 , 36 , 43 ). This was mainly due to the need to maintain the privacy of other women because of shared labour rooms ( 27 , 45 ). Some women did not want their husbands and partners to be present during labour, ( 22 , 27 , 35 ) others preferred female companions ( 45 ), while others wished their husbands to be present to provide emotional support during labour ( 36 , 42 , 43 ). I think women should be allowed their husbands in...my husband was right there with me; my first delivery, it was painful but with his encouragement, he was there holding my hands, doing this, even when the doctors were telling madam push, push, I didn’t listen to the doctors but when my husband say madam push, push, that is when I started pushing. I think it is a psychological thing when your husband is right there with you. ( 36 ) In the majority of the studies, women mentioned the need to have a birth companion to support the mother and baby’s basic needs, such as the provision of food and drinks, going to the toilet, initiating breastfeeding, cleaning the baby, and assistance with mobility, ( 22 , 23 , 35 , 36 , 45 ). Fewer studies quoted the need for emotional support from birth companions ( 23 , 42 ). Instead, women expected healthcare providers, especially midwives to offer emotional support during labour (one-to-one care) since in most contexts birth companions were not allowed inside the labour room ( 23 , 32 , 36 , 41 , 43 ). I came here and met three midwives on duty. They actually supported me. They stood by me until the baby was delivered. One of them even held my hands during delivery and encouraged me throughout the process. They remained with me and responded well to all my numerous requests and questions. They never neglected me and I really appreciated them for that. ( 33 ) Women in LLMICs cited a lack of supportive healthcare providers during labour ( 21 , 24 , 25 , 27 , 28 , 30 , 34 , 40 – 42 , 46 , 47 ). According to women, the factors that affect the responsiveness of HCPs included ignorance, being busy with irrelevant matters such as phone calls, heavy workloads, inadequate staff numbers, and poor working conditions ( 25 , 28 , 34 , 36 , 38 , 42 ) (.. .) So, if someone feels that the baby is coming and it’s time for delivery, she may call for help but only to be disappointed by nurses who think that she is pretending. But because they are busy with their own things, they don't pay attention (.. .) ( 42 ) Continuity of care Only five studies included elements related to women’s experiences of continuity of care during childbirth ( 23 , 24 , 32 , 36 , 48 ). There was variability in women’s preferences of models of continuity of care. One study described women’s preferences for a single provider throughout their pregnancy journey to build trust and reliability of information ( 36 ). Other women indicated their desire for a team of providers with diverse skills to manage their childbirth and respond to complications ( 23 , 48 ). Despite the importance of continuity of services throughout their stay at the health facility, women experienced an interruption of care between shifts, lower quality care, and a lack of monitoring during night shifts ( 24 , 32 , 48 ). I was asked to change bed without being properly cleaned and my blood still dripping on the floor...the provider’s behavior gets worse during night shift ... I will not give birth again in health institutions ( 24 ) In addition, women observed a lack of handover between shifts which resulted in women feeling uninvolved or abandoned and led to the poor communication of critical information between providers causing delays. Some doctors make wrong diagnoses or make wrong decisions. And when one group comes to replace the one that has been treating you, they change the treatment, without asking you any questions or examining you. One team tells that you are for an operation, and another team cancels the operation or tells you that nothing was written. Nobody asks for your opinion and rarely do they answer your questions during rounds. ( 48 ) Pain management Pain relief is crucial for a positive experience and satisfaction with services. A few studies included data concerning women’s experiences of pain management in labour ( 21 , 22 , 24 , 35 , 42 ). A study conducted in Uganda indicated that women perceived labour pain as natural and inevitable, therefore, they did not expect to have medication to manage such pain ( 35 ). However, they expected to get advice on how to deal with pain ( 21 ). I think no need of medicine, because it is natural. I think even if they give you some medicine for pain, contractions would still come because the baby has to come out. I think the drugs cannot reduce those pains...every other woman goes through that ( 35 ) Women described care providers as uncaring and lacking sympathy when they did not provide pain management advice ( 21 , 22 , 24 , 42 ). Women reported enduring surgical interventions without local anaesthesia ( 23 , 42 ). ( ... ) if they had responded in time, maybe my parts wouldn't have been torn. Despite the fact that I was torn, they still stitched me without any pain killer and when I tried to refuse, I was told that I did not bring the required drugs and that if I did not want to be stitched without pain killer I should pay money for the drug and wait for them to go and buy the drugs. So to be honest, I will never ever return to that hospital again ( 42 ) Responsiveness of health facility setting and health services Women perceived timely assessment and management as quality care ( 20 , 23 , 35 , 36 , 44 ). A woman described quality care as follows “[Good quality care is] when you have been received well by the staff at the hospital, and they have helped you quickly” ( 44 ). They emphasized the importance of feeling welcomed by healthcare providers as soon as they arrived at the hospital and throughout their stay for a positive childbirth experience ( 21 – 23 , 25 , 27 , 44 ). Women also valued delivery services available around the clock whenever they needed them and that someone was there to open hospital gates 24/7 ( 20 , 22 , 44 ). Women appreciated it when healthcare providers hastened to examine them when they arrived and provided the needed care ( 20 , 22 , 24 , 33 , 39 , 44 ). In addition, they appreciated it when care providers went out of their way to help them such as midwives providing their personal time and drugs to support women ( 22 ). They treated me with respect because they took good care of me until I delivered and did everything well. After delivery they gave me water for bathing, later I was taken to the bed and they gave me the baby to breastfeed ( 22 ) Women in LLMICs, however, experienced a lack of timely assessment and delays while using health services ( 21 , 22 , 24 , 27 , 28 , 35 , 40 – 42 , 47 ). In addition, women gave birth unattended by HCPs at health facilities due to unavailable, busy or unresponsive staff ( 21 , 24 , 25 , 29 , 34 ). I was examined and told my labour is at an early stage ... at that point, my baby was on the way out but I was restricted to stay in my left side ...I told my care provider I am urged to push down and requested for help ...he said I just examined you (you are not yet ready) and ignored me and continued playing with his mobile phone ...the urge to push down was irresistible, I then turned on my back by myself and gave birth (.. .) ( 24 ) Women highlighted the benefit of having a conducive physical environment and the availability of needed supplies for a positive childbirth experience ( 22 ). Women emphasized the need to have clean facilities (especially delivery wards and bathrooms) with sunlight, access to water, electricity, and sanitation services, adequate beds, uncrowded wards, adequate space and curtains for privacy, and access to bed nets ( 22 , 23 , 36 ). There were also descriptions of negative experiences related to the inadequate physical environment including crowded rooms ( 30 , 36 , 41 , 49 ) insufficient beds ( 26 , 30 , 34 , 36 , 42 ), lack of access to water and food ( 22 , 26 ), dark labour rooms with no natural sunlight ( 22 , 36 ) and unclean premises ( 29 , 36 ). [A]fter delivery there is a room we were taken to sleep, there was no light, no windows, no beddings and we were to stay there feeling cold till morning. That is the worst I experienced... [The room had windows with no glass in them], and it was very cold and we were about three mothers with newly born babies. Cats were just entering through that window and just walking in that hospital...there was lack of security. ( 22 ) Discussion Our meta-synthesis showed that women-centred care, where women are at the centre of their care, respected, and meaningfully involved in choices, is necessary for a positive care experience for women in LLMICs. Women-centred maternity care encompasses effective communication, respect and dignity, and emotional support ( 10 ). These dimensions shape the care experiences of women, how they perceive quality care and their satisfaction with services ( 11 ). Our findings show that women in LLMICs desire the same intrapartum and immediate postpartum care as women in other countries during their period ( 13 ). However, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. For instance, despite the growing interest in the promotion of respectful care ( 50 ), women still encounter disrespectful care in health facilities in LLMICs including physical and verbal abuse, discrimination, and lack of privacy. In line with previous studies, our review indicates that adolescent mothers and unmarried women were more susceptible to mistreatment ( 51 ). In addition, studies indicated poor communication between women and healthcare providers, non-consensual care, and women were rarely involved in their care. A systematic review suggested that women in low-income countries are less likely to expect involvement in care and to demand their rights in the decision-making ( 52 ). Playing a passive role in childbirth could be attributed to cultural and gender norms and the low empowerment of women in the LLMICs ( 4 ). Long-term interventions are required to empower women in these settings, provide them with knowledge of their right to participate in decision-making, and give them the self-assurance to assert those rights ( 53 ). Our findings indicate that women in LLMICs were denied having with them the companion of their choice. In the context of LLMICs, a birth companion offers the woman emotional and practical support and serves as an advocate, expressing her preferences to healthcare professionals and defending her choices. A systematic review indicated that women who had continuous one-to-one support during childbirth had better outcomes than those who lacked support during spontaneous vaginal delivery ( 54 ). Supported women have less need for analgesia, had shorter labours and were satisfied with the intrapartum services they received ( 54 ). The same systematic review suggested that having continuous support throughout labour may promote respectful care and safeguard against the mistreatment of women during childbirth ( 54 ). As illustrated in our findings, the non-clinical aspects of care play an essential role in shaping the experiences of care, satisfaction with services, and future care-seeking behaviours. According to a systematic review, even when evidence-based clinical criteria are followed, maternity services are deemed low quality if they are disrespectful to the women receiving them ( 55 ). Nevertheless, investment in interventions to improve non-clinical aspects of care such as respectful care, meaningful involvement of women in their care, and effective communication during childbirth are often not a priority in LLMICs settings ( 19 ). Despite the recent global recognition of the significance of respectful care, a lack of political will and quality maternity care guidelines, in addition to limited resources in LLMICs have put interventions to enhance women’s experiences at the bottom of the agenda ( 4 , 55 , 56 ). Our findings indicate that most women gave birth in health facilities with limited infrastructure and resources indicating the need for government investment in LLMICs. Nevertheless, there are cost-effective interventions that can help improve the quality of care such as training healthcare providers on interpersonal communication, mentoring, and setting accountability systems where women can voice their experiences and expectations ( 56 ). Women reported fewer occurrences of disrespectful care, according to a systematic review of studies from Kenya, Tanzania, Sudan, and South Africa that examined the impact of implementing measures to improve respectful maternity care ( 56 ). A before-and-after intervention study evaluated the impact of implementing a bundle of respectful maternity care policies in 13 facilities in Kenya including training of care providers, capacity building of quality improvement teams at facilities, caring for Carers which included counselling of care providers on coping with stress, and community activities including community workshops to educate the public about their rights ( 57 ). This study revealed a decrease in the incidence of observed disrespectful care and abuse of women ( 57 ). These interventions were effective as the package targeted health facilities, women, care providers, and the community which acknowledges the interconnectivity between these different actors and the socio-cultural environment at local facilities and community ( 56 , 57 ). For instance, the same study showed a discrepancy between reported and observed disrespectful care due to the low expectations of women regarding their care. Therefore, it is essential to have interventions to raise women’s awareness regarding their rights ( 57 ). There are different models regarding the organization of care during pregnancy, including midwife-led continuity of care, obstetrician-provided care, family doctor-provided care, or shared model of care where health services are provided by a team of providers ( 58 ). Our findings indicate the paucity of evidence with regard to the continuity of care during childbirth in LLMICs. A systematic review showed that women who had midwifery-led care had an increased likelihood of a spontaneous vaginal delivery and reduction in pre-term labour; however, the evidence was lacking the long-term maternal and baby wellbeing outcomes ( 59 ). Our review indicated that women preferred having a single care provider throughout their pregnancy journey to build their trust, confidence, and smooth transition to parenthood. A study that assessed the quality of services provided by midwives in Uganda indicated that midwives provided low-quality services for women ( 60 ). According to the study, weak knowledge and skills of midwives are attributed to inadequate in-service training, lack of supportive supervision, and absence of written guidelines ( 60 ). A systematic review examining the reasons why midwives do not provide quality services in Low- and Middle-Income Countries showed that weak or absent midwifery regulations and heavy workloads were major barriers ( 61 ). Besides, short training courses that midwives receive before their midwifery practice as a temporary solution to improve coverage with skilled birth attendance have a negative impact on the quality of care they provide, especially for those working in remote areas with support from the health system ( 61 ). These limitations related to midwifery education and regulations, the skills of midwives in LLMICs, and the supportive environment can probably jeopardize the application of midwife-led continuity of care in LLMICs. Further research is required about the feasibility and effectiveness of implementing a midwife-led approach in the context of health facilities in LLMICs, short and long-term outcomes given the current limitations. Our review did not specifically focus on the experiences and expectations of women in fragile settings. However, a third of the included articles was conducted in countries classified as fragile states ( 62 ) including Ethiopia, Guinea, and Nigeria. Health systems in fragile states suffer unique challenges, including insecurity, reliance on international support, weak leadership and management, and insufficient human and financial resources for health ( 63 , 64 ). In these contexts, midwives play an important role in providing maternal care given their knowledge, skills, and closeness to communities ( 65 ). Evidence shows that investments in improving the quality of midwifery education and regulations are cost efficient and can enhance the quality of maternity care and women-centred outcomes in humanitarian settings and stable developing settings ( 65 , 66 ). Our review indicates that there is a paucity of research that explores the views of women in fragile states regarding quality maternity care, the status, and the contextual factors that affect women-centred outcomes. Prioritizing context-relevant interventions based on the needs and expectations of women in general and especially marginalized women resonates with a key cornerstone of the Sustainable Development Goals, reducing inequities in access to quality services, and leaving no one behind. Limitations Our qualitative meta-synthesis has a few limitations. Some articles had minimal methodological rigor, in addition, the findings were rather descriptive and lacked explanatory models. Furthermore, researchers were not explicit about theoretical frameworks and forms of inquiry. We included all eligible articles, even if they were of low quality, as an attempt to incorporate all women’s voices. However, the reported themes may have been limited by the quality of the original articles. We also noticed that the majority of included articles lacked researcher reflexivity and they did not fully describe study limitations. A lack of detail concerning the research methodology can result in questions regarding the trustworthiness of the findings and the possible misinterpretation of participants’ voices. Implications for policy and practice Quality health systems cater to the needs of the population they serve. The planning of interventions to improve the quality of maternity care must be based on communication with women and women groups to identify context-specific factors to optimize implementation and outcomes. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Designing systems that capture women’s needs can be challenging in the context of LLMICs unless there is a commitment from policymakers, health programs, and practitioners. Our findings indicate that women in LLMICs received sub-quality intrapartum care and global standards for women-centred care were often compromised. Given the limitations that health systems in LLMICs have, including lack of quality maternal health guidelines, limited health financing, and resources, we predict that the global standards for a positive childbirth experience are hard to achieve in these settings. Therefore, a set of minimum indicators for women-centred outcomes that work in the context of LLMICs is needed. In addition, we recommend actionable strategies to enhance the quality of maternity care based on women’s needs and preferences. Indicators can quantitatively measure women’s care experiences including dignified and respectful care, autonomy, effective communication, involvement in care, access to emotional support, and supportive care and physical environment. We recommend that the indicators related to women’s care experiences be integrated with national health indicators in LLMICs to provide a database that can be used to monitor countries' progress in improving the quality of maternity health services. Conclusion To improve care seeking and satisfaction with health services, women-centred care, where women and their newborns are at the centre of their care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Further research is needed to set minimum indicators for women-centred outcomes that work in the context of sub-Saharan African LLMICs along with actionable strategies to enhance the quality of maternity care based on women’s needs and preferences. Abbreviations CASP: Critical Appraisal Skills Programme HCPs: Health care providers LLMICs: Low and Low Middle-Income Countries MMAT: Mixed Methods Appraisal Tool PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses PROSPERO: The International Prospective Register of Systematic Reviews SBA: Skilled birth attendant SDGs: Sustainable Development Goals SSA: Sub-Saharan Africa WHO: World Health Organisation Declarations Ethics approval and consent to participate Not applicable for this review. Consent for publication Not applicable for this review. Availability of data and materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this study. Authors' contributions SAEA, AM, and AD conceptualized the study, SAEA wrote the review protocol, and AM and AD reviewed and approved the final protocol. SAEA conducted the literature search, imported citations into Covidence, and removed duplicates. SAEA, AM, and AD (two authors per citation) screened the title and abstracts of papers and conducted the full-text assessment for inclusion. All authors were involved with the quality assessment of included articles. SAEA developed the data extraction excel sheet and extracted first-order constructs and second-order relevant to review objectives. All authors analysed and interpreted the data. SAEA drafted the manuscript. All authors contributed to the intellectual content, read and approved the final manuscript. Acknowledgements We would like to thank the librarian, Ana Shah Hosseani at the University of Technology Sydney who provided support and knowledge in developing and performing the literature search. 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Human resources for health. 2019;17(1):1-16. Renfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. The Lancet. 2014;384(9948):1129-45. Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Supplementaryfile2.docx Supplementaryfile3.docx Supplementaryfile4.docx Supplementaryfile5.docx Cite Share Download PDF Status: Published Journal Publication published 14 Jan, 2023 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Major revision 17 Nov, 2022 Reviews received at journal 02 Nov, 2022 Reviewers agreed at journal 14 Oct, 2022 Reviews received at journal 04 Oct, 2022 Reviewers agreed at journal 29 Sep, 2022 Reviewers invited by journal 15 Sep, 2022 Editor assigned by journal 10 Sep, 2022 Editor invited by journal 09 Sep, 2022 Submission checks completed at journal 09 Sep, 2022 First submitted to journal 31 Aug, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2019687","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":135524836,"identity":"7b16b1cb-5cce-4132-a1e2-0b0a17344b27","order_by":0,"name":"Salma A.E. Ahmed","email":"data:image/png;base64,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","orcid":"","institution":"University of Technology Sydney","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Salma","middleName":"A.E.","lastName":"Ahmed","suffix":""},{"id":135524837,"identity":"d96a3102-0b83-4bd3-b322-1987ec467daf","order_by":1,"name":"Abela Mahimbo","email":"","orcid":"","institution":"University of Technology Sydney","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abela","middleName":"","lastName":"Mahimbo","suffix":""},{"id":135524838,"identity":"6d8f14dd-65c2-4a83-b56b-2002b86a7673","order_by":2,"name":"Angela Dawson","email":"","orcid":"","institution":"University of Technology Sydney","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Dawson","suffix":""}],"badges":[],"createdAt":"2022-09-01 01:29:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2019687/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2019687/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-022-05319-1","type":"published","date":"2023-01-14T18:18:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":27024763,"identity":"6bf95b60-87fc-48cb-8bd3-c6dfc01259a2","added_by":"auto","created_at":"2022-09-27 13:42:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50992,"visible":true,"origin":"","legend":"\u003cp\u003eScreening and selection process\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2019687/v1/6eb0adfc4f5ffd3503406bbc.png"},{"id":44716459,"identity":"314c9708-dc04-4682-a3cc-a9f748448df2","added_by":"auto","created_at":"2023-10-16 18:26:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":730656,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2019687/v1/b6ce798f-325c-4b51-832f-f065dabf32f7.pdf"},{"id":27024492,"identity":"3834d6b5-6ad7-4ff6-8059-1426dd89fb13","added_by":"auto","created_at":"2022-09-27 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13:47:03","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16637,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-2019687/v1/3585dc9b004f5f2427e43e51.docx"},{"id":27024496,"identity":"3f629d6f-03b8-475d-b715-1cfb1fee1eb0","added_by":"auto","created_at":"2022-09-27 13:37:03","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":16690,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-2019687/v1/fb7be414dbe2e997d436a5bf.docx"},{"id":27024493,"identity":"cf32a592-be23-4c03-a01c-911dcbbf9090","added_by":"auto","created_at":"2022-09-27 13:37:03","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":14714,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile5.docx","url":"https://assets-eu.researchsquare.com/files/rs-2019687/v1/843dc304d414a4b4ad97e1a0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quality intrapartum care expectations and experiences of women in sub- Saharan African Low and Low Middle-Income Countries: A qualitative meta- synthesis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMany countries have made significant progress toward decreasing maternal mortality; however, much work is required to reach the Sustainable Development Goal (SDG) global target of less than 70 per 100,000 live births by 2030 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). Eighty percent of maternal deaths are preventable (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). An estimated 295,000 maternal deaths occurred globally in 2017 due to pregnancy and delivery-related causes (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite the substantial progress of countries toward increasing access to maternity services, this has not been reflected in decreasing maternal mortality and morbidity as much as expected (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). This mismatch between health outcomes and access to services is attributed to the poor quality of services provided to women during pregnancy, childbirth, and postpartum periods (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). The reduction in maternal and neonatal deaths requires a rapid improvement in the quality and coverage of health services in low and low-middle-income countries (LLMICs).\u003c/p\u003e\n\u003cp\u003eA fundamental strategy for reducing maternal mortality is increasing access to skilled attendance during childbirth. Skilled birth attendance involves trained, competent, and motivated health workers delivering evidence-based interventions in an enabling environment (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e). A skilled birth attendant (SBA) is a care provider, often a nurse, a midwife, or a doctor, trained to manage normal delivery, detect danger signs, and refer women in a timely manner to receive specialized care (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). An enabling environment involves the presence of essential medicines and equipment, alongside a functioning referral system (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). Globally, around 80% of births are assisted by a skilled attendant (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). However, the coverage of skilled birth attendance varies within countries and across regions. Seventy-seven percent of births are attended by an SBA in Central and Southern Asia while around 59% of births are attended by a skilled provider in Sub-Saharan Africa (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWhile women are encouraged to give birth to their babies with the assistance of a skilled provider in a health facility, facilities may be understaffed, overcrowded, and provide low-quality services (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). A systematic review of factors affecting the provision of maternal services in LLMICs has shown that lack of supportive supervision, understaffing, and high workloads of care providers contribute to the decreased quality of services (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). Moreover, low salaries and poor working conditions also contribute to provider stress and performance alongside a lack of equipment and medicines (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). The initiatives to increase the coverage of skilled birth attendance must go hand in hand with strategies to guarantee that women receive quality services before, during, and after childbirth.\u003c/p\u003e\n\u003cp\u003eWomen-centred maternity care is defined as respectful care that is responsive to women\u0026rsquo;s needs, values, and preferences (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). In 2018, the World Health Organization (WHO) published a set of recommendations for a positive experience during pregnancy and childbirth as part of their support for global high-quality antenatal, delivery, and postnatal care (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). These recommendations embrace the optimization of the health and well-being of women and their babies through a women-centred approach rather than a focus on the prevention of mortality and morbidity during pregnancy. In this model, the WHO describes intrapartum care as\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA platform to provide pregnant women with respectful, individualized, woman-centred, and effective clinical and non-clinical practices to optimize birth outcomes for the woman and her baby, by skilled healthcare providers in a well-functioning healthcare system\u003c/em\u003e (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eA systematic review explored women\u0026rsquo;s needs during childbirth globally in 2018, however, the majority of studies included in this review were conducted in high and middle-income countries, and only included three studies were from African Sub-Saharan (SSA) LLMICs (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). To our knowledge, no systematic review has been published that focuses on the expectations of women in SSA LLMICs and what women regard as quality care during childbirth. The perspectives of women on what matters to them will support the evidence base for the contextualization and operationalization of WHO guidelines on intrapartum care for a positive childbirth experience in SSA LLMICs. The findings can inform the planning, implementation, and appraisal of maternity services which includes the development of women-centred policies and service guidelines.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis qualitative meta-synthesis was conducted following a priori protocol registered on The International Prospective Register of Systematic Reviews (PROSPERO) (Ref. CRD42021292682). Qualitative meta-synthesis is a structured approach to summarizing, collating, and interpreting primary qualitative data and the interpretations reported in peer-reviewed articles (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e). A preliminary scoping was done prior to the development of the protocol to refine the review question, determine the feasibility of the review and the nature of current evidence, and decide the method of synthesis. The review question was \u0026ldquo;what are the intrapartum midwifery care experiences and expectations of women of quality care in SSA LLMICs\u0026rdquo;. We designed and reported this review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"Section2\"\u003e\n \u003ch2\u003eSearch strategy and study selection:\u003c/h2\u003e\n \u003cp\u003eWe developed a search strategy for qualitative and mixed-methods peer-reviewed articles published between 2011 and 2021. The electronic search was run using eight databases including MEDLINE (Ovid), Global Health, EMBASE (Ovid), CINAHL Plus, Web of Science, SCOPUS, Africa Journals Online (AJOL), and the Maternity and Infant Care Index. The search terms included three main concepts; expectations or satisfaction of women, quality intrapartum care, and eligible geographical scope and countries. Please refer to Supplementary file 1 for a sample of the search strategies used for MEDLINE (Ovid). All searches were conducted from the 13th of December 2021 to the 16th of December 2021. All citations retrieved from electronic searches in databases were imported into a web-based software platform, Covidence, which is used for the management of collation of citations, removal of duplicates, and screening processes. The first author carried out this phase. Two authors independently screened the title and abstracts of identified citations using Covidence. Furthermore, two authors per citation screened full texts for eligibility using inclusion and exclusion criteria (Supplementary file 2) for the final included studies selected (n\u0026thinsp;=\u0026thinsp;30) (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Disagreements during screening were resolved by discussions of the research team and having a third opinion. The searches of the targeted databases yielded 7197 citations. After the screening of title and abstracts, full texts of potential eligible 43 articles were retrieved. After exclusions, 30 articles were included in this systematic review (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003e(Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e comes here)\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\"\u003e\n \u003ch2\u003eQuality appraisal\u003c/h2\u003e\n \u003cp\u003eTwo reviewers independently appraised included studies using a quality appraisal checklist. We used the Critical Appraisal Skills Programme (CASP) checklist to assess the quality of peer-reviewed qualitative studies (Supplementary files 3 and 4) (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). Whereas, mixed methods peer-reviewed articles, we used the Mixed Methods Appraisal Tool (MMAT) (Supplementary file 5) (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e). Disagreements during quality appraisal were resolved by discussion of the team. Quality appraisal tools were used to highlight the strengths and weaknesses of studies to assist in the interpretation of the findings. No studies were excluded during the quality appraisal process.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\"\u003e\n \u003ch2\u003eData extraction, analysis, and synthesis\u003c/h2\u003e\n \u003cp\u003eData that included first-order constructs i.e. women\u0026rsquo;s views and accounts and second-order constructs i.e. authors\u0026rsquo; interpretations relevant to review objectives, were extracted and summarized by the first author using a data extraction excel sheet. The data extraction sheet was developed by the first author for the purpose of this review and it was piloted in the extraction of data from three articles prior to use. The variables included characteristics of the articles including the aims, number and demographic features of the study population, the study context, responsiveness, dignified care and respect, access to emotional support during childbirth, patient-provider communication and engagement, continuity of care, pain management, and responsive healthcare providers and physical environment during childbirth. The sheet included a description of what elements were included in each theme for consistency.\u003c/p\u003e\n \u003cp\u003eBased on the purpose of the review and the heterogeneous nature of the qualitative evidence, we conducted a thematic synthesis in two stages (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e). The first stage included data reduction and thematic extraction of primary study findings (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) based on the WHO intrapartum care model for a positive childbirth experience, (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) i.e. within-study analysis. While the second stage entailed a cross-studies thematic synthesis using a deductive and inductive approach (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis qualitative meta-synthesis included 30 articles from nine African Sub-Saharan Low and Low-Middle Income Countries, including Ethiopia (n\u0026thinsp;=\u0026thinsp;6), Ghana (n\u0026thinsp;=\u0026thinsp;3), Guinea (n\u0026thinsp;=\u0026thinsp;1), Kenya (n\u0026thinsp;=\u0026thinsp;4), Malawi (n\u0026thinsp;=\u0026thinsp;6), Nigeria (n\u0026thinsp;=\u0026thinsp;3), Tanzania (n\u0026thinsp;=\u0026thinsp;2), Uganda (n\u0026thinsp;=\u0026thinsp;3), Tanzania and Zambia (n\u0026thinsp;=\u0026thinsp;1), and Uganda and Nigeria (n\u0026thinsp;=\u0026thinsp;1). The characteristics of the articles are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most studies explored the experiences of women and their views concerning the quality of intrapartum care (n\u0026thinsp;=\u0026thinsp;17). However, some studies included women\u0026rsquo;s partners as well (n\u0026thinsp;=\u0026thinsp;3), different categories of healthcare providers, community health workers, and community leaders (n\u0026thinsp;=\u0026thinsp;10).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included articles\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e#\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountry/ies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAim\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEligible study population\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfulani et al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003cp\u003eFocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo examine women\u0026rsquo;s facility-based childbirth experiences in a rural county in Kenya and aspects of care that contribute to a positive or negative birth experience.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKumbani et al. (2012)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study \u003c/p\u003e \u003cp\u003ein depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u0026rsquo;s perceptions on perinatal care among the women delivered at a district hospital.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJolly et. al (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003cp\u003ein-depth interviews and key-informant interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u0026rsquo;s perceptions regarding respectful maternity care and the knowledge and understanding of the seven domains of the RMC Charter among healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64 women (recruited from antenatal, intrapartum and postnatal clinics)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eO\u0026rsquo;Donnell et al. (2014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003cp\u003ein depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePerceptions of women and HCPs of maternity care in a rural setting in Malawi.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaya et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExploratory qualitative study \u003c/p\u003e \u003cp\u003ein depth interviews\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u0026rsquo;s perspectives of mistreatment during facility-based childbirth in the Ghanaian context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e110 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDalinjong et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative part of a bigger convergent mixed-methods study\u003c/p\u003e \u003cp\u003eFocus group discussions \u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities and to explore women and health providers\u0026rsquo; views on privacy and satisfaction with quality of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewomen in postnatal period (number of women who participated in the FGD sessions is not provided)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNamujju et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhenomenological qualitative study \u003c/p\u003e \u003cp\u003eIn-depth interviews and focus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo describe the childbirth experiences and the perceived meanings among postnatal mothers to broaden the information base for appropriate intervention development and individualized care during childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfulani et al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative part of a bigger mixed methods study\u003c/p\u003e \u003cp\u003eIn-depth interviews and focus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrevalence and determinants of birth companionship, and women and providers\u0026rsquo; perceptions of it in health facilities in a rural County in Western Kenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBohren et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda and Nigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExploratory qualitative study \u003c/p\u003e \u003cp\u003ein depth interviews\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore what \u0026ldquo;quality of care\u0026rdquo; means to childbearing women in Nigeria and Uganda,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePostnatal women (number of women who participated in the FGD sessions is not provided)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKyaddondo et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFormative qualitative study \u003c/p\u003e \u003cp\u003ein depth interviews\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe experiences, expectations, and needs of urban Ugandan women in relation to good-quality facility childbirth.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMehretie Adinew and Abera Assefa (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExploratory qualitative study \u003c/p\u003e \u003cp\u003eIn-depth interviews and\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore why some women with previous experience of facility-based delivery care gave birth at home for their most recent child by in-depth understanding of women\u0026rsquo;s previous facility-based delivery experience, perspective towards health facilities and service providers with regard to delivery services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMcMahon et. al. (2014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study (grounded theory)\u003c/p\u003e \u003cp\u003e in depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo understand how rural Tanzanian women and their male partners describe disrespect and abuse experienced during childbirth in facilities and how they respond to abuse in the short or long-term\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDzomeku et.al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExploratory qualitative research\u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore women's experiences with childbirth care in Kumasi, Ghana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56 women (attending antenatal or postnatal care)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOluoch-Aridi et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study \u003c/p\u003e \u003cp\u003ein depth interviews and\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe experiences and perceptions of women and healthcare workers regarding mistreatment during childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKaye et. al. (2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhenomenological qualitative study \u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo gain a deeper understanding of mothers\u0026rsquo; perspectives on quality of care (the structure, process and outcome of intrapartum care) particularly during duty handovers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMadula et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study \u003c/p\u003e \u003cp\u003ein depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo examine the nature of communication in the maternity ward, and to identify facilitators and barriers to healthcare provider-patient communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 women (recruited from antenatal or postnatal clinic)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMselle et. al. (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study \u003c/p\u003e \u003cp\u003ein depth interviews and\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe experiences of mothers and fathers in relation to mistreatment during childbirth in Tanzania.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMalachi et. al. (2016)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative part of a bigger mixed methods study\u003c/p\u003e \u003cp\u003eIn-depth interviews and key informant interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo evaluate the institutional factors influencing women\u0026rsquo;s perception of quality intrapartum care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewomen in postnatal period (number of women participated in the FGD session is not provided)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDebela et. al. (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative part of a bigger mixed methods study\u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore underlying determinants of maternal satisfaction towards institutional delivery care among mothers who gave birth in public health facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBurrowes et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u0026rsquo;s experiences of midwifery care during labor and to explore midwives\u0026rsquo; understandings of patients\u0026rsquo; rights and patient-centered care and their experiences with patient abuse and disrespect;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBohren et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study \u003c/p\u003e \u003cp\u003eIn-depth interviews and\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore women and providers\u0026rsquo; experiences and perceptions of mistreatment during childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBalde et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGuinea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study \u003c/p\u003e \u003cp\u003eIn-depth interviews and\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore the perceptions and experiences of women and HCPs of mistreatment during childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e109 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJiru and Sendo (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExploratory qualitative study\u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore women\u0026rsquo; and midwives\u0026rsquo; perceptions of compassionate and respectful care during facility-based delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsrese (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative part of a bigger mixed methods study\u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo assess the quality of intrapartum care experienced by mothers at health centers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLavender et. al. (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTanzania and Zambia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study (grounded theory)\u003c/p\u003e \u003cp\u003eIn-depth interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExploring care through multiple lenses enabling a more comprehensive understanding of relational contributors to experiences through examining the intrapartum experiences of women, partners, different health-providers and key stakeholders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOjelade et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study \u003c/p\u003e \u003cp\u003ein depth interviews and\u003c/p\u003e \u003cp\u003efocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u0026rsquo;s needs for communication and emotional support during facility- based childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMgawadere et. al. (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003equalitative study\u003c/p\u003e \u003cp\u003eFocus group discussions and key-informant interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore women\u0026rsquo;s and healthcare provider\u0026rsquo;s perspectives of what quality of care during childbirth means to them\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e134 women (postpartum)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrpin et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhenomenological qualitative study \u003c/p\u003e \u003cp\u003eFocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTo explore the women experiences of disrespect and abuse during pregnancy, childbirth, and in the postnatal period and its impact on the future use of health facilities for maternity care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 women (postnatal)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMachira and Palamuleni (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative study\u003c/p\u003e \u003cp\u003eFocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u0026rsquo;s perspectives on the quality of maternal health care services in Malawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGebremichael et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhenomenological qualitative study \u003c/p\u003e \u003cp\u003eFocus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen\u0026rsquo;s experience of disrespect and abuse during childbirth at health facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e62 women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe present the women\u0026rsquo;s experiences and expectations regarding quality intrapartum care categorized according to the themes; dignified care and respect, communication and meaningful engagement in care, access to emotional support during childbirth, continuity of care, pain management, and responsiveness of health facility setting and health services. Our findings indicate that women in Sub-Saharan LLMICs need clinical and non-clinical staff to treat them with respect and in a non-discriminatory and non-abusive manner. In addition, women wanted to feel welcomed throughout their stay in health facilities. Women described the need to be meaningfully involved in their care and to have open and effective communication with their care providers which helped them prepare for labour. Women also wanted to be emotionally and physically supported by care providers and their birth companions. The findings show that women expect to receive timely care and be monitored closely in a safe environment at health facilities.\u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDignified care and respect\u003c/h2\u003e \u003cp\u003eWomen demanded to be treated with respect during childbirth and expected healthcare providers to be non-judgmental (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), kind (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and respectful (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). For a positive childbirth experience, women described needing respectful and dignified intrapartum care while maintaining their privacy and wanting to be meaningfully engaged in their care (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In addition to health care providers (HCPs), the positive attitude of non-clinical staff, such as cleaners and security guards also contributed to a positive experience (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Women described dignified care that involved physical support (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhen I was in labor, a nurse brought me porridge for me to have energy during delivery of the baby. I saw that I was respected\u003c/em\u003e (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDisrespectful care was also reported by women in LLMICs who were verbally and physically abused during childbirth and suffered discrimination as a result of their age, ethnicity, literacy level, and socioeconomic status (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eRespectful. The first thing which comes to my mind ... the client must be respected. Respected that is ... to receive care ... not (taking into account) age, worth, colour or religion\u003c/em\u003e (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eVerbal and physical abuse includes shouting, yelling, ridicule, judgmental remarks from healthcare providers, and slapping and whipping of women during childbirth. In few studies, however, women considered the abusive behaviour of healthcare providers as a normative behaviour (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) or they expected to be shouted at (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) or provided sociocultural and contextual justifications for their behaviour such as encouragement of women, stress, and poor working conditions (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Women encounter discrimination as well based on their tribes, age, literacy level, and socioeconomic status (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). A study conducted in Zambia and Tanzania classified discrimination into two categories; direct and indirect, direct discrimination includes discriminatory incidents that happen to women during childbirth whereas indirect discrimination was defined as when women received poor quality of care caused by policies that are meant for everyone such as the assignment of professionals to central and referral facilities instead of rural areas (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Studies showed that young girls giving birth or unmarried women received judgmental remarks from HCPs (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Women demanded to be treated impartially without discrimination and considered being treated by non-judgmental HCPs as essential for a positive childbirth experience (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWomen in LLMICs also reported experiencing a lack of privacy during childbirth and unnecessary physical exposure due to contextual factors such as crowded wards and poor infrastructure at health facilities (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eDue to the lack of infrastructure and congestion of hospitals, it was hard to maintain the privacy of women in such context so it was not uncommon to have several women giving birth in the same room - so women need privacy during childbirth with curtains or cubicles\u003c/em\u003e (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, one study indicated that privacy was not a big concern for women in that context compared to not having care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In addition, women could not complain about the lack of privacy because they feared retribution from care providers (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e comes here)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes reported in primary articles\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSource\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDignified care and respect\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunication and meaningful engagement in care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAccess to emotional support during childbirth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eContinuity of care\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003epain management\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eResponsiveness\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfulani et al.(2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportance of the positive attitude of staff for a positive childbirth experience\u003c/p\u003e \u003cp\u003eNegative experiences related to dignified care and respect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s needs related to communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificance of emotional and physical support from HCPs for a positive childbirth experience \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNegative experiences related to pain management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSignificance of physical environment in having a positive experience\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s needs regarding responsiveness and physical environment\u003c/p\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKumbani et al. (2012)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive and negative experiences related to dignified care and respect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNegative experiences related to pain management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSignificance of feeling welcomed\u003c/p\u003e \u003cp\u003eNegative experiences related to responsiveness \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJolly et. al (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpectations of women regarding respectful care\u003c/p\u003e \u003cp\u003eImportance of non-judgmental HCPs for a positive childbirth experience \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen\u0026rsquo;s ability to make informed decisions\u003c/p\u003e \u003cp\u003eWomen\u0026rsquo;s needs related to communication during childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSignificance of support around the clock and timeliness of care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eO\u0026rsquo;Donnell et al. (2014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive experiences related to access to emotional support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSignificance of feeling welcomed and timeliness of care for positive experience\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaya et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003cp\u003eExpectations of women regarding respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSignificance of feeling welcomed for positive experience\u003c/p\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDalinjong et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNamujju et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRoles of birth companion in provision of support during labor \u003c/p\u003e \u003cp\u003ePreferences of women regarding birth companions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePerceptions of women related to labor pain \u003c/p\u003e \u003cp\u003eNegative experiences related to pain management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfulani et al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReasons why women need a birth companion\u003c/p\u003e \u003cp\u003ePositive and negative experiences related to birth companion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBohren et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003cp\u003eExpectations of women regarding respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpectations of women regarding communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExpectations of women related to access to emotional support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExpectations of women regarding continuity of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWomen\u0026rsquo;s needs regarding physical environment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKyaddondo et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen expectations regarding respectful care \u003c/p\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificance of communication for a positive childbirth experience\u003c/p\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWomen\u0026rsquo;s needs related to emotional support during childbirth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExpectations of women regarding continuity of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWomen\u0026rsquo;s needs regarding physical environment \u003c/p\u003e \u003cp\u003eSignificance of feeling welcomed for a positive experience \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMehretie Adinew and Abera Assefa (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNegative experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcMahon et. al. (2014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDzomeku et.al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePositive experiences related to responsiveness of staff\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOluoch-Aridi et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNegative experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaye et. al. (2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWomen expectations regarding continuity of care \u003c/p\u003e \u003cp\u003eNegative experiences related to continuity of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMadula et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePositive experiences related to responsiveness of staff\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMselle et. al. (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive and negative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificance of effective communication for satisfaction with services \u003c/p\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeeds of women regarding birth companion\u003c/p\u003e \u003cp\u003eand support from healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNegative experiences related to pain management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalachi et. al. (2016)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to inadequate physical environment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDebela et. al. (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAccess to psychological support during labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurrowes et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNegative experiences related to access to support\u003c/p\u003e \u003cp\u003ePreferences of women regarding birth companion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNegative experiences related to continuity of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBohren et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003cp\u003eWomen perceived contributing factors of mistreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalde et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJiru and Sendo (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsrese (2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative experiences related to communication and engagement in care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive and negative experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLavender et. al. (2021)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor experiences were tolerated as long as their babies are fine\u003c/p\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOjelade et. al. (2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificance of effective communication for a positive childbirth experience \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeeds of women related to access to support\u003c/p\u003e \u003cp\u003eNegative experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMgawadere et. al. (2019)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificance of effective communication for a positive childbirth experience \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInfrastructural factors behind denial of birth companion \u003c/p\u003e \u003cp\u003eNegative experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSignificance of feeling welcomed for positive experience\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrpin et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen perceived contributing factors of mistreatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMachira and Palamuleni (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNegative experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNegative experiences related to responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGebremichael et. al. (2018)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative experiences related to respectful care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePositive experiences related to access to support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNegative experiences related to continuity of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNegative experiences related to pain management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enegative experiences related to Responsiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCommunication and meaningful engagement in care\u003c/h2\u003e \u003cp\u003eIn half of the included studies, women described their experiences and expectations regarding communication with health providers and engagement in care. Women in LLMICs reported that open, effective, clear, two-way communication where HCPs used positive language and were able to ask questions as an important aspect of quality care and satisfaction with delivery services (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). A women stated \u0026ldquo;\u003cem\u003eCommunication is very, very important...it is everything\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). They appreciated it when HCPs sought their consent and gave them regular updates about their progress in labour (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and they referred to having open communication as \u0026lsquo;friendship\u0026rsquo; with care providers (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThey [healthcare providers] should continuously ask questions... \u0026lsquo;how do you feel,\u0026rsquo; \u0026lsquo;how are you feeling now.\u0026rsquo; It\u0026rsquo;s not supposed to just be the woman that will be telling them \u0026lsquo;please come check on me\u0026rsquo;...they [healthcare providers] should be continuously telling the woman \u0026lsquo;this is your condition,\u0026rsquo; and educate them.\u003c/em\u003e(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen cited poor communication during childbirth (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) that included the inability to ask questions (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), HCPs not introducing themselves or not using women\u0026rsquo;s names (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), communication difficulties for women living with disability (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), and communication in languages other than their mother tongue (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Women also spoke of a lack of information that made them feel unprepared and caused stress during the labour (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In addition, communication gaps resulted in misinterpretation of providers\u0026rsquo; motivations (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies indicated that women were rarely involved in decision-making in LLMICs (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). For instance, women did not understand why care providers opted to use a specific management plan (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In addition, women were not involved in choosing their delivery positions (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The midwives did not even engage me in any discussions over my childbirth process. They never told or asked me about anything\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in LLMICs wanted to be listened to and be meaningfully involved in decision-making in actions affecting their care such as preferred labour position, treatment options, and others (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAccess to emotional support during childbirth\u003c/h2\u003e \u003cp\u003eThe experiences and expectations of women regarding emotional support through labour were detailed in the majority of studies. According to the voices of women in the papers included in this review, labour constituted an important and stressful occasion that substantiates emotional support throughout their stay at the health facilities. Women wanted to be cared for and encouraged to go through labour with a birth companion of their choice (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eGood quality of care is when you come to a health facility, you are received, they know what that moment means to you and that of your child and the kind of reception they give you as a mother that wants to deliver her child. They receive you warmly, encourage you. .. what matters most is that when you come into a health facility, there\u0026rsquo;s this confidence derived that assures one that she\u0026rsquo;s in good hands.\u003c/em\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in LLMICs are accompanied by their mothers, sisters, mothers-in-law, husbands, and \u003cem\u003edoula\u003c/em\u003e (a traditional birth attendant or an older woman from their communities) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Husbands in the majority of facilities where studies took place were not allowed inside the labour room (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). This was mainly due to the need to maintain the privacy of other women because of shared labour rooms (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome women did not want their husbands and partners to be present during labour, (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) others preferred female companions (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), while others wished their husbands to be present to provide emotional support during labour (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI think women should be allowed their husbands in...my husband was right there with me; my first delivery, it was painful but with his encouragement, he was there holding my hands, doing this, even when the doctors were telling madam push, push, I didn\u0026rsquo;t listen to the doctors but when my husband say madam push, push, that is when I started pushing. I think it is a psychological thing when your husband is right there with you.\u003c/em\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the majority of the studies, women mentioned the need to have a birth companion to support the mother and baby\u0026rsquo;s basic needs, such as the provision of food and drinks, going to the toilet, initiating breastfeeding, cleaning the baby, and assistance with mobility, (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Fewer studies quoted the need for emotional support from birth companions (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Instead, women expected healthcare providers, especially midwives to offer emotional support during labour (one-to-one care) since in most contexts birth companions were not allowed inside the labour room (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI came here and met three midwives on duty. They actually supported me. They stood by me until the baby was delivered. One of them even held my hands during delivery and encouraged me throughout the process. They remained with me and responded well to all my numerous requests and questions. They never neglected me and I really appreciated them for that.\u003c/em\u003e (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in LLMICs cited a lack of supportive healthcare providers during labour (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). According to women, the factors that affect the responsiveness of HCPs included ignorance, being busy with irrelevant matters such as phone calls, heavy workloads, inadequate staff numbers, and poor working conditions (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e(.. .) So, if someone feels that the baby is coming and it\u0026rsquo;s time for delivery, she may call for help but only to be disappointed by nurses who think that she is pretending. But because they are busy with their own things, they don't pay attention (.. .)\u003c/em\u003e (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eContinuity of care\u003c/h2\u003e \u003cp\u003eOnly five studies included elements related to women\u0026rsquo;s experiences of continuity of care during childbirth (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). There was variability in women\u0026rsquo;s preferences of models of continuity of care. One study described women\u0026rsquo;s preferences for a single provider throughout their pregnancy journey to build trust and reliability of information (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Other women indicated their desire for a team of providers with diverse skills to manage their childbirth and respond to complications (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the importance of continuity of services throughout their stay at the health facility, women experienced an interruption of care between shifts, lower quality care, and a lack of monitoring during night shifts (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI was asked to change bed without being properly cleaned and my blood still dripping on the floor...the provider\u0026rsquo;s behavior gets worse during night shift ... I will not give birth again in health institutions\u003c/em\u003e (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition, women observed a lack of handover between shifts which resulted in women feeling uninvolved or abandoned and led to the poor communication of critical information between providers causing delays.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSome doctors make wrong diagnoses or make wrong decisions. And when one group comes to replace the one that has been treating you, they change the treatment, without asking you any questions or examining you. One team tells that you are for an operation, and another team cancels the operation or tells you that nothing was written. Nobody asks for your opinion and rarely do they answer your questions during rounds.\u003c/em\u003e (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePain management\u003c/h2\u003e \u003cp\u003ePain relief is crucial for a positive experience and satisfaction with services. A few studies included data concerning women\u0026rsquo;s experiences of pain management in labour (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). A study conducted in Uganda indicated that women perceived labour pain as natural and inevitable, therefore, they did not expect to have medication to manage such pain (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). However, they expected to get advice on how to deal with pain (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI think no need of medicine, because it is natural. I think even if they give you some medicine for pain, contractions would still come because the baby has to come out. I think the drugs cannot reduce those pains...every other woman goes through that\u003c/em\u003e (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen described care providers as uncaring and lacking sympathy when they did not provide pain management advice (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Women reported enduring surgical interventions without local anaesthesia (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e( ... ) if they had responded in time, maybe my parts wouldn't have been torn. Despite the fact that I was torn, they still stitched me without any pain killer and when I tried to refuse, I was told that I did not bring the required drugs and that if I did not want to be stitched without pain killer I should pay money for the drug and wait for them to go and buy the drugs. So to be honest, I will never ever return to that hospital again\u003c/em\u003e (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eResponsiveness of health facility setting and health services\u003c/h2\u003e \u003cp\u003eWomen perceived timely assessment and management as quality care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). A woman described quality care as follows \u003cem\u003e\u0026ldquo;[Good quality care is] when you have been received well by the staff at the hospital, and they have helped you quickly\u0026rdquo;\u003c/em\u003e(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). They emphasized the importance of feeling welcomed by healthcare providers as soon as they arrived at the hospital and throughout their stay for a positive childbirth experience (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Women also valued delivery services available around the clock whenever they needed them and that someone was there to open hospital gates 24/7 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Women appreciated it when healthcare providers hastened to examine them when they arrived and provided the needed care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In addition, they appreciated it when care providers went out of their way to help them such as midwives providing their personal time and drugs to support women (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThey treated me with respect because they took good care of me until I delivered and did everything well. After delivery they gave me water for bathing, later I was taken to the bed and they gave me the baby to breastfeed\u003c/em\u003e (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in LLMICs, however, experienced a lack of timely assessment and delays while using health services (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). In addition, women gave birth unattended by HCPs at health facilities due to unavailable, busy or unresponsive staff (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI was examined and told my labour is at an early stage ... at that point, my baby was on the way out but I was restricted to stay in my left side ...I told my care provider I am urged to push down and requested for help ...he said I just examined you (you are not yet ready) and ignored me and continued playing with his mobile phone ...the urge to push down was irresistible, I then turned on my back by myself and gave birth (.. .)\u003c/em\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen highlighted the benefit of having a conducive physical environment and the availability of needed supplies for a positive childbirth experience (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Women emphasized the need to have clean facilities (especially delivery wards and bathrooms) with sunlight, access to water, electricity, and sanitation services, adequate beds, uncrowded wards, adequate space and curtains for privacy, and access to bed nets (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). There were also descriptions of negative experiences related to the inadequate physical environment including crowded rooms (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) insufficient beds (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), lack of access to water and food (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), dark labour rooms with no natural sunlight (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and unclean premises (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e[A]fter delivery there is a room we were taken to sleep, there was no light, no windows, no beddings and we were to stay there feeling cold till morning. That is the worst I experienced... [The room had windows with no glass in them], and it was very cold and we were about three mothers with newly born babies. Cats were just entering through that window and just walking in that hospital...there was lack of security.\u003c/em\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur meta-synthesis showed that women-centred care, where women are at the centre of their care, respected, and meaningfully involved in choices, is necessary for a positive care experience for women in LLMICs. Women-centred maternity care encompasses effective communication, respect and dignity, and emotional support (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These dimensions shape the care experiences of women, how they perceive quality care and their satisfaction with services (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Our findings show that women in LLMICs desire the same intrapartum and immediate postpartum care as women in other countries during their period (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. For instance, despite the growing interest in the promotion of respectful care (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), women still encounter disrespectful care in health facilities in LLMICs including physical and verbal abuse, discrimination, and lack of privacy. In line with previous studies, our review indicates that adolescent mothers and unmarried women were more susceptible to mistreatment (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). In addition, studies indicated poor communication between women and healthcare providers, non-consensual care, and women were rarely involved in their care. A systematic review suggested that women in low-income countries are less likely to expect involvement in care and to demand their rights in the decision-making (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Playing a passive role in childbirth could be attributed to cultural and gender norms and the low empowerment of women in the LLMICs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Long-term interventions are required to empower women in these settings, provide them with knowledge of their right to participate in decision-making, and give them the self-assurance to assert those rights (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur findings indicate that women in LLMICs were denied having with them the companion of their choice. In the context of LLMICs, a birth companion offers the woman emotional and practical support and serves as an advocate, expressing her preferences to healthcare professionals and defending her choices. A systematic review indicated that women who had continuous one-to-one support during childbirth had better outcomes than those who lacked support during spontaneous vaginal delivery (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Supported women have less need for analgesia, had shorter labours and were satisfied with the intrapartum services they received (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). The same systematic review suggested that having continuous support throughout labour may promote respectful care and safeguard against the mistreatment of women during childbirth (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs illustrated in our findings, the non-clinical aspects of care play an essential role in shaping the experiences of care, satisfaction with services, and future care-seeking behaviours. According to a systematic review, even when evidence-based clinical criteria are followed, maternity services are deemed low quality if they are disrespectful to the women receiving them (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Nevertheless, investment in interventions to improve non-clinical aspects of care such as respectful care, meaningful involvement of women in their care, and effective communication during childbirth are often not a priority in LLMICs settings (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Despite the recent global recognition of the significance of respectful care, a lack of political will and quality maternity care guidelines, in addition to limited resources in LLMICs have put interventions to enhance women\u0026rsquo;s experiences at the bottom of the agenda (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur findings indicate that most women gave birth in health facilities with limited infrastructure and resources indicating the need for government investment in LLMICs. Nevertheless, there are cost-effective interventions that can help improve the quality of care such as training healthcare providers on interpersonal communication, mentoring, and setting accountability systems where women can voice their experiences and expectations (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Women reported fewer occurrences of disrespectful care, according to a systematic review of studies from Kenya, Tanzania, Sudan, and South Africa that examined the impact of implementing measures to improve respectful maternity care (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). A before-and-after intervention study evaluated the impact of implementing a bundle of respectful maternity care policies in 13 facilities in Kenya including training of care providers, capacity building of quality improvement teams at facilities, caring for Carers which included counselling of care providers on coping with stress, and community activities including community workshops to educate the public about their rights (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). This study revealed a decrease in the incidence of observed disrespectful care and abuse of women (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). These interventions were effective as the package targeted health facilities, women, care providers, and the community which acknowledges the interconnectivity between these different actors and the socio-cultural environment at local facilities and community (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). For instance, the same study showed a discrepancy between reported and observed disrespectful care due to the low expectations of women regarding their care. Therefore, it is essential to have interventions to raise women\u0026rsquo;s awareness regarding their rights (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are different models regarding the organization of care during pregnancy, including midwife-led continuity of care, obstetrician-provided care, family doctor-provided care, or shared model of care where health services are provided by a team of providers (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Our findings indicate the paucity of evidence with regard to the continuity of care during childbirth in LLMICs. A systematic review showed that women who had midwifery-led care had an increased likelihood of a spontaneous vaginal delivery and reduction in pre-term labour; however, the evidence was lacking the long-term maternal and baby wellbeing outcomes (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Our review indicated that women preferred having a single care provider throughout their pregnancy journey to build their trust, confidence, and smooth transition to parenthood. A study that assessed the quality of services provided by midwives in Uganda indicated that midwives provided low-quality services for women (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). According to the study, weak knowledge and skills of midwives are attributed to inadequate in-service training, lack of supportive supervision, and absence of written guidelines (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). A systematic review examining the reasons why midwives do not provide quality services in Low- and Middle-Income Countries showed that weak or absent midwifery regulations and heavy workloads were major barriers (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Besides, short training courses that midwives receive before their midwifery practice as a temporary solution to improve coverage with skilled birth attendance have a negative impact on the quality of care they provide, especially for those working in remote areas with support from the health system (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). These limitations related to midwifery education and regulations, the skills of midwives in LLMICs, and the supportive environment can probably jeopardize the application of midwife-led continuity of care in LLMICs. Further research is required about the feasibility and effectiveness of implementing a midwife-led approach in the context of health facilities in LLMICs, short and long-term outcomes given the current limitations.\u003c/p\u003e \u003cp\u003eOur review did not specifically focus on the experiences and expectations of women in fragile settings. However, a third of the included articles was conducted in countries classified as fragile states (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e) including Ethiopia, Guinea, and Nigeria. Health systems in fragile states suffer unique challenges, including insecurity, reliance on international support, weak leadership and management, and insufficient human and financial resources for health (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). In these contexts, midwives play an important role in providing maternal care given their knowledge, skills, and closeness to communities (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). Evidence shows that investments in improving the quality of midwifery education and regulations are cost efficient and can enhance the quality of maternity care and women-centred outcomes in humanitarian settings and stable developing settings (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Our review indicates that there is a paucity of research that explores the views of women in fragile states regarding quality maternity care, the status, and the contextual factors that affect women-centred outcomes. Prioritizing context-relevant interventions based on the needs and expectations of women in general and especially marginalized women resonates with a key cornerstone of the Sustainable Development Goals, reducing inequities in access to quality services, and leaving no one behind.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOur qualitative meta-synthesis has a few limitations. Some articles had minimal methodological rigor, in addition, the findings were rather descriptive and lacked explanatory models. Furthermore, researchers were not explicit about theoretical frameworks and forms of inquiry. We included all eligible articles, even if they were of low quality, as an attempt to incorporate all women\u0026rsquo;s voices. However, the reported themes may have been limited by the quality of the original articles. We also noticed that the majority of included articles lacked researcher reflexivity and they did not fully describe study limitations. A lack of detail concerning the research methodology can result in questions regarding the trustworthiness of the findings and the possible misinterpretation of participants\u0026rsquo; voices.\u003c/p\u003e \u003cp\u003eImplications for policy and practice\u003c/p\u003e \u003cp\u003eQuality health systems cater to the needs of the population they serve. The planning of interventions to improve the quality of maternity care must be based on communication with women and women groups to identify context-specific factors to optimize implementation and outcomes. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Designing systems that capture women\u0026rsquo;s needs can be challenging in the context of LLMICs unless there is a commitment from policymakers, health programs, and practitioners.\u003c/p\u003e \u003cp\u003eOur findings indicate that women in LLMICs received sub-quality intrapartum care and global standards for women-centred care were often compromised. Given the limitations that health systems in LLMICs have, including lack of quality maternal health guidelines, limited health financing, and resources, we predict that the global standards for a positive childbirth experience are hard to achieve in these settings. Therefore, a set of minimum indicators for women-centred outcomes that work in the context of LLMICs is needed. In addition, we recommend actionable strategies to enhance the quality of maternity care based on women\u0026rsquo;s needs and preferences. Indicators can quantitatively measure women\u0026rsquo;s care experiences including dignified and respectful care, autonomy, effective communication, involvement in care, access to emotional support, and supportive care and physical environment. We recommend that the indicators related to women\u0026rsquo;s care experiences be integrated with national health indicators in LLMICs to provide a database that can be used to monitor countries' progress in improving the quality of maternity health services.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo improve care seeking and satisfaction with health services, women-centred care, where women and their newborns are at the centre of their care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Further research is needed to set minimum indicators for women-centred outcomes that work in the context of sub-Saharan African LLMICs along with actionable strategies to enhance the quality of maternity care based on women\u0026rsquo;s needs and preferences.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCASP: Critical Appraisal Skills Programme\u003c/p\u003e\n\u003cp\u003eHCPs: Health care providers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLLMICs: Low and Low Middle-Income Countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMMAT: Mixed Methods Appraisal Tool\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePROSPERO: The International Prospective Register of Systematic Reviews\u003c/p\u003e\n\u003cp\u003eSBA: Skilled birth attendant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDGs: Sustainable Development Goals\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSSA: Sub-Saharan Africa\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organisation\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable for this review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable for this review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSAEA, AM, and AD conceptualized the study, SAEA wrote the review protocol, and AM and AD reviewed and approved the final protocol. SAEA conducted the literature search, imported citations into Covidence, and removed duplicates. SAEA, AM, and AD (two authors per citation) screened the title and abstracts of papers and conducted the full-text assessment for inclusion. All authors were involved with the quality assessment of included articles. SAEA developed the data extraction excel sheet and extracted first-order constructs and second-order relevant to review objectives. All authors analysed and interpreted the data. SAEA drafted the manuscript. All authors contributed to the intellectual content, read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the librarian, Ana Shah Hosseani at the University of Technology Sydney who provided support and knowledge in developing and performing the literature search.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organisation. Global health observatory data: maternal mortality 2017 [Available from: http://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/.\u003c/li\u003e\n\u003cli\u003eMselle LT, Moland KM, Mvungi A, Evjen-Olsen B, Kohi TW. Why give birth in health facility? Users\u0026rsquo; and providers\u0026rsquo; accounts of poor quality of birth care in Tanzania. BMC health services research. 2013;13(1):174.\u003c/li\u003e\n\u003cli\u003eGraham WJ, McCaw-Binns A, Munjanja S. 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International Journal of Gynecology \u0026amp; Obstetrics. 2017;139:27-37.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Donnell E, Utz B, Khonje D, Van Den Broek N. \u0026lsquo;At the right time, in the right way, with the right resources\u0026rsquo;: perceptions of the quality of care provided during childbirth in Malawi. BMC pregnancy and childbirth. 2014;14(1):1-6.\u003c/li\u003e\n\u003cli\u003eAfulani P, Kusi C, Kirumbi L, Walker D. Companionship during facility-based childbirth: results from a mixed-methods study with recently delivered women and providers in Kenya. BMC pregnancy and childbirth. 2018;18(1):1-28.\u003c/li\u003e\n\u003cli\u003eDalinjong PA, Wang AY, Homer CS. Are health facilities well equipped to provide basic quality childbirth services under the free maternal health policy? Findings from rural northern Ghana. BMC health services research. 2018;18(1):1-9.\u003c/li\u003e\n\u003cli\u003eDebela AB, Mekuria M, Kolola T, Bala ET, Deriba BS. 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Health in fragile states. Medicine, Conflict and Survival. 2014;30(1):19-27.\u003c/li\u003e\n\u003cli\u003eNewbrander W, Waldman R, Shepherd‐Banigan M. Rebuilding and strengthening health systems and providing basic health services in fragile states. Disasters. 2011;35(4):639-60.\u003c/li\u003e\n\u003cli\u003eBeek K, McFadden A, Dawson A. The role and scope of practice of midwives in humanitarian settings: a systematic review and content analysis. Human resources for health. 2019;17(1):1-16.\u003c/li\u003e\n\u003cli\u003eRenfrew MJ, McFadden A, Bastos MH, Campbell J, Channon AA, Cheung NF, et al. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. The Lancet. 2014;384(9948):1129-45.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Women-centred care, intrapartum care, quality of care, experiences, expectations, sub-Sahara Africa, Low and Low Middle-Income Countries","lastPublishedDoi":"10.21203/rs.3.rs-2019687/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2019687/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eWomen-centred maternity care is respectful and responsive to women\u0026rsquo;s needs, values, and preferences. Women\u0026rsquo;s views and expectations regarding the quality of health services during pregnancy and childbirth vary across settings. Despite the need for context-relevant evidence, to our knowledge, no reviews focus on what women in sub-Saharan African Low and Low Middle-Income Countries (LLMICs) regard as quality intrapartum care that can inform quality guidelines in countries.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eWe undertook a qualitative meta-synthesis using a two-stage thematic synthesis to identify the experiences and expectations of women in sub-Saharan African LLMICs with quality intrapartum care. Following a priori protocol, we searched eight databases for primary articles using keywords. We used Covidence to collate citations, remove duplicates, and screen articles using a priori set inclusion and exclusion criteria. Two authors independently screened first the title and abstracts, and the full texts of the papers. Using a data extraction excel sheet, we extracted first-order constructs and second-order relevant to review objectives. The WHO framework for a positive childbirth experience underpinned data analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 7197 identified citations, 30 articles were included in this review. Women\u0026rsquo;s needs during the intrapartum period resonate with what women want globally, however, priorities regarding the components of quality care for women and the urgency to intervene differed in this context given the socio-cultural norms and available resources. Women received sub-quality intrapartum care and global standards for women-centred care were often compromised. They were mistreated verbally and physically. Women experienced poor communication with their care providers and non-consensual care and were rarely involved in decisions concerning their care. Women were denied the companion of choice due to cultural and structural factors.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTo improve care seeking and satisfaction with health services, women-centred care is necessary for a positive childbirth experience. Women must be meaningfully engaged in the design of health services, accountability frameworks, and evaluation of maternal services. Research is needed to set minimum indicators for women-centred outcomes for low-resource settings along with actionable strategies to enhance the quality of maternity care based on women\u0026rsquo;s needs and preferences.\u003c/p\u003e","manuscriptTitle":"Quality intrapartum care expectations and experiences of women in sub- Saharan African Low and Low Middle-Income Countries: A qualitative meta- synthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-09-27 13:37:01","doi":"10.21203/rs.3.rs-2019687/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-11-17T10:27:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-11-02T17:48:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3595c5bb-cabd-4788-b965-c961d8394f8b","date":"2022-10-14T13:16:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-10-04T10:38:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92ac645a-f8d1-4209-8ba9-9d81ea7f5c0c","date":"2022-09-29T08:28:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-09-15T08:20:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-09-10T07:49:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-09-09T18:56:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-09-09T18:54:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2022-09-01T01:24:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7e54134-d13b-450c-92b4-7e0938b4769f","owner":[],"postedDate":"September 27th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:22:29+00:00","versionOfRecord":{"articleIdentity":"rs-2019687","link":"https://doi.org/10.1186/s12884-022-05319-1","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2023-01-14 18:18:24","publishedOnDateReadable":"January 14th, 2023"},"versionCreatedAt":"2022-09-27 13:37:01","video":"","vorDoi":"10.1186/s12884-022-05319-1","vorDoiUrl":"https://doi.org/10.1186/s12884-022-05319-1","workflowStages":[]},"version":"v1","identity":"rs-2019687","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2019687","identity":"rs-2019687","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}