Healthcare Providers' Perspectives on Sustaining Respectful Maternity Care Appreciated by Mothers, in Five Hospitals of Rwanda

Healthcare Providers' Perspectives on Sustaining Respectful Maternity Care Appreciated by Mothers, in Five Hospitals of Rwanda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Healthcare Providers' Perspectives on Sustaining Respectful Maternity Care Appreciated by Mothers, in Five Hospitals of Rwanda Alice Muhayimana, Irene Kearns This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3824494/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Childbirth demands respect, as emphasized by the World Health Organization in 2018 and the focus towards the need for positive, dignified delivery experiences, has become an integral aspect of Respectful Maternity Care (RMC). It is a known fact that RMC is pivotal for favorable birth outcomes and reduce mistreatment during childbirth. Absence of RMC violates women and newborns' rights, and the study aims to explore Health Care Providers' perspectives on sustaining RMC actions previously reported by mothers. Methodology : This study was conducted in five hospitals in the Eastern province of Rwanda, involving 5 Focus Group Discussions (FGDs) with midwives and nurses. For interviews, we purposively selected 5-unit managers and 5 physicians. Additionally, 40 midwives and nurses were recruited for the FGDs. The research utilized the Dream phase of Appreciative Inquiry (AI) for interviews and Focus Groups. Data collection aimed to gain insights into Healthcare Providers' perceptions of how RMC is provided and how to establish and to sustain RMC in Rwandan health facilities. Nvivo 12 was employed for organizing codes and creating a codebook, and thematic analysis was applied. Results : 4 themes emerged and their sub-themes.1) Women centered care with Compassionate care, Privacy and confidentiality maintenance, Information provision and liberty in decision making, Effective communication, Family involvement , Cleanness Equality care. 2) Professionalism compliance with Motivated staff, Teamwork, Continuous development, Quality work provision, Community trust. 3) RMC encounters 4) RMC sustenance Conclusion and recommendations : The continuous pursuit of high RMC standards in Rwanda involves improving childbirth experiences through utilizing existing resources, ongoing improvement, and sustaining achievements. Key recommended actions in this study for sustaining RMC encompass promoting women-centered care, enhancing healthcare provider attitudes, ensuring professionalism, building community trust, maintaining conducive health facility environments, and involving leadership positive childbirth appreciative care best practices mother-friendly care Rwanda 1. Introduction In the era of striving to achieve the Sustainable Development Goals (SDGs), countries worldwide, including Rwanda, aim to meet all goals and targets by 2030, employing various strategies. This study specifically focuses on one target of SDG number 3: to end all preventable deaths of maternal and newborns ( 14 ), and one target of SDG number 5: to eliminate all forms of violence against women and girls ( 5 ). Childbirth, a significant human experience, demands respect. The intrapartum and immediate postpartum period pose a high risk for both mother and newborn, necessitating high-quality care ( 41 ). White Ribbon Alliance (WRA) defined Respectful maternity care (RMC) as a human right of every woman and her baby of being treated with care, respect and dignity, free from harm, and to maintain absolute liberty and autonomy ( 39 ). Therefore, RMC is not an option, it is a basic human right. World Health Organization (WHO) in 2018 stated that RMC extends beyond the mere prevention of maternal morbidity and death. It emphasizes the need of ensuring that women have a pleasant delivery experience, which entails being treated with utmost respect and dignity ( 2 ) ( 35 ). In 2018, WHO shifted its focus towards ensuring a positive childbirth experience, emphasizing its importance ( 40 ). Mistreatment towards mothers during childbirth contributes to the poor quality of maternity care they receive ( 3 ). Studies argue that Disrespect and Abuse (D&A) can inflict long-term psychological damage and emotional trauma, diminishing women's confidence and self-esteem ( 28 ). Being disrespected may lead to feelings of shame, sorrow, insecurity, distrust in healthcare staff, a sense of powerlessness, and reluctance to seek help ( 28 ). Memories of labor and delivery experiences persist throughout a woman's lifetime and are often shared with others ( 3 ) ( 38 ). Disrespectful and abusive care instils fear of future utilization of maternity services, reducing their use, which, in turn, hinders safe motherhood and contributes to increased adverse maternal and neonatal outcomes ( 3 ) ( 28 ). D&A is a violation of fundamental human rights ( 39 ). Rwanda has made significant strides in maternal and neonatal health, achieving Millennium Development Goals through initiatives like skilled birth attendants, family planning, and Community Health Workers (CHWs) since 2009. CHWs play a pivotal role in promoting maternal and newborn care at the household level. The introduction of RapidSMS technology in 2010 synchronized health systems, and increased ambulance services improved transfer of laboring pregnant women to health facilities. Mandatory health insurance coverage since 2008, with 91% coverage, ensures access to healthcare ( 30 ). Rwanda's notable progress in prioritizing women's rights indeed, Rwanda has made significant strides in promoting gender equality, particularly in political representation. The country has surpassed many others in terms of the percentage of women in parliamentary positions, showcasing a commitment to empowering women at various levels of society. Ultimately, this commitment to respect and gender equality contributes to the overall development and progress of the nation ( 37 ). It sets a positive example for other countries and highlights the idea that empowering women is not only a matter of rights but also a strategic investment in the social and economic prosperity of the nation. The absence of overt disrespect or abuse during childbirth doesn't guarantee the presence of RMC practices; for instance, the absence of physical abuse doesn't necessarily indicate the existence of compassionate and positive care behaviors ( 18 ). RMC and mistreatment during childbirth represent opposite ends of a spectrum. Research indicates that women and newborns can experience a mix of both positive RMC practices and negative mistreatment behaviors within this range ( 18 ). Providing RMC plays a crucial role in enhancing the quality and utilization of maternity services ( 40 ) ( 11 ) ( 16 ). Advocating for RMC is essential for advancing the Sustainable Development Goals (SDGs), particularly in achieving the targets of eliminating preventable maternal and neonatal deaths and ending all forms of violence against women ( 25 ). Although in 2018, WHO launched a shift towards promoting positive childbirth experiences, appreciative RMC practices have largely remained under examined in academic literature ( 5 ), particularly in Rwanda, where very little is known about the perceptions of healthcare providers (HCPs) towards maternity care received by mothers. Little is known regarding perceptions of HCPs regarding RMC provision in Rwanda. Ndirima published findings on perceptions of maternity services at Mibilizi District Hospital in Rwanda's Western Province. The study involved rural women who had hospital births. The mothers commonly emphasized the need for respectful treatment in spaces which offering ample privacy, preferences regarding the gender of the birth attendant and the potential presence of their husbands during the childbirth process. Women in these remote areas make considerable effort to access healthcare facilities, with positive expectations, however the staff shortages pose obstacles ( 29 ). Violations against the women’s dignity and respect were reported by women in labour in health facilities of Rwanda ( 33 ). Women were slapped, verbally berated, humiliated, reprimanded, physically assaulted, insulted, abandoned, denied having birth companion and some were subjected to inappropriate and rough handling by healthcare providers. A significant number reported being shouted at for failing to follow instructions, and some were retained within hospitals due to unsettled bills ( 28 ). In addition, women were being subjected to shouts and derogatory remarks from HCPs ( 33 ). 2. Methodology Research Design This study employed an exploratory qualitative descriptive design, incorporating both Focus Group Discussions (FGD) and individual interviews as methods of data collection. The data collection approach utilized Appreciative Inquiry (AI), encouraging participants to reflect on their most positive experiences and perceptions and fostering a constructive and empowering perspective ( 36 ) ( 7 ). This study is a part of a doctoral project aimed at gaining insights into healthcare professional’s perceptions of RMC, with the overarching goal of developing strategies to promote RMC in Rwanda Appreciative Inquiry approach Appreciative Inquiry embraces a 5D cycle that consists of the Definition, Discovery, Dream, Design and Destiny phases according to ( 36 ) ( 7 ). This 5D cycle allowed the participants to share their best moments of RMC and their expectations for RMC. In this study, the dream phase was only involved since the participants mainly narrated their views to sustain RMC. DREAM phase The Dream phase envisions a positive future, building on qualities discovered in the Discovery phase. It inspires discussions on favourable outcomes with the question, "What will your ideal success (for RMC) look like?" This phase fosters enthusiasm and collaborative vision, preparing for practical actions. In this study, the dream phase was based on the information gotten from the interviews and Focus groups, participants envisioned themselves how the maternity care services could operate at their best. Participants thought widely and holistically on the future they want. Through different varieties of imagining, the HCPs were asked to envisage and portrait RMC for the future ( 36 ) ( 7 ). Setting and population The research was conducted at five hospitals located in the Eastern province of Rwanda. The study involved a sample of 50 healthcare providers (HCPs) working in maternity services, including medical doctors, midwives, and nurses. Ten in-depth interviews were conducted, involving five medical practitioners and five maternity unit supervisors (matrons) ( refer to Table 1 ). Additionally, five Focus Group Discussions were held, with the participation of 40 midwives and nurses working in maternity care ( refer to Table 2 ). The investigation took place in May 2023. In general, participants were asked about their opinions on the findings reported by mothers in a previous study ( 27 ). Data collection The interview was conducted in either Kinyarwanda or English, depending on the participant's preferred language. Demographic details were collected using a demographic questionnaire. In-depth information was elicited through probing questions. Participants were informed that mothers value compassionate care, and we asked for their suggestions on providing care free from harm and ill-treatment, as well as ways to demonstrate empathy. The interviewer emphasized that mothers appreciated autonomy and independence and asked the participants on how to achieve this. The interviewer asked the participants how they can grant mothers the decision-making liberty, allowing mothers to express their choices and preferences, and providing to them relevant information. Additionally, participants were informed that mothers value efficient care, and the interviewer sought their input on achieving this while sustaining dignified care, respect, and maintaining privacy and confidentiality. Furthermore, HCPs were informed that mothers expressed a desire for a normal delivery, getting a healthy baby, and staying in a clean and tidy environment. The interview inquired about actions that can be taken to uphold these preferences. HCPs were also informed that mothers typically perceive HCPs who provide RMC as those who have love for people and passion for the profession, the interviewer asked how these aspects can be sustained. HCPs were then reminded that the community holds varying perspectives, both positive and negative, regarding the care women receive during labour and the birth process and they were asked to propose ways to regain the community's trust, along with interventions or actions from HCPs that would demonstrate RMC. Furthermore, HCPs were queried about the methods they view as respectful towards a woman in labour, from a healthcare provider's perspective, from hospital management, and within health facilities. Following the conclusion of each interview, the researcher stressed the significance of subsequent communication via telephone calls to review the study findings and confirm their precise representation of participants' perceptions. Throughout the discussions, field notes were documented, and any fresh insights offered by participants were integrated into the analyzed data. Data Analysis After each interview, the audio recordings were immediately transcribed word for word. Guided by the principal investigator, a research assistant translated these transcripts into English, simplifying the process and maintaining data integrity. To verify accuracy, these translations were then reverse translated into Kinyarwanda. The research employed an inductive thematic analysis approach, utilizing pertinent quotes to convey the findings. To deeply engage with the data, the researcher extensively reviewed the transcripts. The Nvivo 12 software played a crucial role in organizing the transcribed data. The research team initiated the process by carefully listening to the recorded audio, ensuring the completeness and integrity of the data through cross-referencing with transcriptions. To gain a thorough understanding of the content, the team meticulously examined the transcripts ( 21 ). They utilized line-by-line coding to identify initial codes, which were then evaluated to establish categories based on similarities and differences in participants' responses. This process involved an iterative approach, with the team continually revisiting and refining the categories while cross-referencing with the original transcripts to ensure they accurately captured participants' genuine experiences and perspectives ( 21 ). This rigorous analysis led to the identification of primary themes. To validate these themes, select participants were consulted through a process known as member checking ( 15 ), ensuring that the themes resonated with their perceptions. Subsequently, an inductive thematic analysis was conducted, complemented by relevant quotes to comprehensively present the findings ( 31 ). Trustworthiness measure To ensure the trustworthiness of the research findings in this study, the researcher adhered to the evaluative criteria for rigor in qualitative research. These criteria, as outlined by Lincoln and Guba ( 23 ) and Grove and Burns ( 15 ), encompass credibility, dependability, confirmability, and transferability. Credibility, was ensured by deliberately selecting healthcare providers who met eligibility criteria, using open-ended questions in interviews to elicit detailed responses, and incorporating peer debriefing and member checking during data collection and analysis. Sharing transcripts for accuracy confirmation further enhanced credibility. Dependability was maintained by meticulously documenting decisions from research initiation to data analysis, creating a comprehensive audit trail. Data stability was also upheld through timely and consistent collection under similar conditions within a specific, relatively short period. Confirmability was maintained by relying solely on participant narratives for analysis, avoiding the imposition of the researcher's assumptions ( 8 ) ( 15 ). Transferability was enhanced by providing a detailed description of the study's setting, sample, and investigated phenomenon using a well-structured interview guide. 3. Results Table 1. socio-demographic data from individual interviews The majority (70%) of participants who took part in the interview were aged between 25 and 35. Among them, 80% were male, and 60% had experience of up to only five years Table 2. Demographic data from Focus Groups About half of the participants in the FGD fell within the age range of 31 to 35 (49.5%). The majority of participants were midwives (72.5%), and approximately half of them had accumulated one to five years of experience working in maternity services. Variables Categories Frequency Percentage% Age 25–30 11 27.5 31–35 19 47.5 36 and above 10 25 Sex Female 30 75 Male 10 25 Midwife 29 72.5 Nurses 11 27.5 Experience in maternity 1–5 years 20 50 6–10 years 15 37.5 11 years and above 5 12.5 During thematic analysis, four themes and sub-themes emerged from the data: 1) Women centered care with Compassionate care, Privacy and confidentiality maintenance, Information provision and liberty in decision making, Effective communication, Family involvement, Cleanliness of environment, Equality care. 2) Professionalism compliance with Motivated staff, Teamwork, Continuous development, Quality work provision, Community trust. 3) RMC encounters 4) RMC sustenance 1. Women centered-care 1.1 Compassionate care Healthcare providers emphasized the importance of showing compassion to mothers. They stressed the need to put themselves in the client's shoes, treat the mother with empathy, reflect on ethical considerations, ensure her confidentiality, care for her with a good heart, make the mother feel relaxed, and show love and hope. They added that truly compassionate service would be achieved if a doctor treated every mother as if she were his/her own mother, wife, or sister. HCP reported that performing episiotomy without anesthesia is no longer exist. ‘’We need to have a heart of love and patience. In maternity, there is hard work, but we should have the heart to love people. So first we should strengthen love in ourselves and then have the gift of patience … What we should do for the mothers to show them compassion first is to put ourselves in their position because if we put ourselves in their place.” FGD1 HCPs reported that mothers should understand that labor pain is natural and normal. HCPs support labor by reassuring the mothers, providing back massages, encouraging them to ambulate, and ensuring emotional well-being by offering comforting words. Service providers reported having insufficient knowledge about labor painkiller medications. “An area where we have little knowledge is pain relief for the mother in labor. Pain management is not appropriately done but we teach them with the help of the Bible”. FGD 5 1.2 Privacy and confidentiality maintenance HCPs stated that privacy is maintained by using curtains between beds, but they recommend the use of rooms because curtains sometimes do not ensure confidentiality. They reported that confidentiality is maintained during the handover process, labeling laboratory samples, and medical rounds, where they use medical terms, signs, and identifiers. In our study sites, participants reported that they no longer use printed files; instead, they utilize technology (such as open clinic) to store client information, with everyone having an individual password to log in. However, uncertainty about how to prevent maternity information from being accessed by providers from other services was expressed. On one study site, they reported that maternity is planned to be built with rooms therefore birth companionship will be possible. “Mainly, we care about the information we give to the mothers, their information is confidential, and we care about privacy”. IDI, matron, female, 34 years 1.3 Information provision and liberty in decision making Midwives reported that a mother has the right to request information and receive it, and she also has the right to make choices and express preferences. Participants reported that the rights and responsibility of the clients are written on the hospital wall. Some information for mother and neonatal care is being provided. Some participants mentioned that during reception, customer care services welcome the mothers, and allowed them to contact the representative of customer care services at any time during their stay in the hospital. Additionally, before being admitted, mothers are required to sign a consent form. Participants recommended that women's rights should be posted in a visible location for mothers to read. “There is a customer care representative of the hospital, her photo and number are available, they call her if they can't find the matron if a person has a problem and brings it to customer care, it is solved quickly ”. IDI, matron, female, 33 years Participants emphasized that mothers have the right to make their own decisions before receiving care. A mother may not have knowledge about her health; therefore, HCPs should first provide all information to the mother by explaining the pros and cons, allowing her to make a decision, and then sign the consent. “The care is central to women, not to us. She is the one who is going into the labor, she is the one who is going to bear any procedure that we are going to perform on her, so she has the right to refuse the treatment.” IDI, doctor, male, 30 years. Participants reported that a mother has the right to choose the treatment; for example, she has the right to opt for a cesarean section without medical indication. The decision-making process for a mother's treatment should be done as quickly as possible so that HCPs can take action without unnecessary delays. 1.4 Effective communication To facilitate communication between clients, service providers and hospital management, they have a suggestion box for clients to share their ideas. After reading these suggestions, they can make decisions accordingly. Additionally, in some hospitals, there is a book where clients can submit any eventual complaints and measures can be implemented when there is evidence of disrespect. There is a way to handle incidence of disrespect. ‘’When there is an incidence of disrespect; We have a quality book, whoever is found to have happened is approached and discussed and we can register her in the book and also resolve issue with the victim. If happens for the second time, the case is presented to the higher authorities for punishment’’ IDI, matron, female,33 years To handle disrespect issue, HCPs from one hospital reported that they manage it at their level or they refer to mental health services “If a client is physically or psychologically harmed by a healthcare provider, the first is to prevent the spreading of information. In our measures, we have a team leader who must handle the problem and approach the family to find a solution. If it is beyond our control, we can use the mental health service to help us.” IDI, matron, male,27years To improve client-provider communication, providers should explain the labor process to the clients, giving them time to ask questions freely. Listening to them and providing feedback during this process helps to establish trust. ‘’If you have confidence in explaining to the mother how things are going, and when you explain directly to her, she immediately trusts you’’ . IDI. Doctor, male, 37 years Participants advised HCPs first to introduce themselves to the mother. Taking time to read the client's file and talking with the client helps avoid harm. Explaining everything to the mother, including information on the baby's care, lab tests, and results, is crucial. Participants emphasized the importance of consented care, stating that service providers should explain everything they do and its significance, ensuring that mothers also understand. Providers should also clarify what is and is not allowed in the hospital, explaining their rights and responsibilities. They added that sometimes it is challenging to find time to provide all explanations to the mother. “First we respect her rights. Respecting the right of the mother is to listen to her, to explain to her what she wants to know.” FGD1 1.5 Family involvement HCPs argue that a mother has the right to involve her family in her care process, and service providers help the mother to achieve that. Midwives used to involve a birth companion to assist in the mother's care. However, the infrastructure hinder the birth companion from staying with the mother during the second stage of labour and is a significant challenge. “The mother has the right to involve her family in the treatment when she wants, so that the male companion can come if she asks us, but when she doesn't ask, we have to treat her according to her rights.” FGD 3 1.6 Cleanness Service providers argue that they encourage mothers to maintain personal hygiene. For infection prevention, HCPs used to request mothers to wear diapers during labor to prevent spreading of vaginal leakage, however, some mothers with traditional beliefs resist wearing those diapers. Providers ensure the cleanliness of beds and rooms and encourage mothers to maintain personal cleanliness as well. Cleanliness in the service is maintained, and there are cleaners specifically for the maternity ward and follow waste management measures. There is a daily cleaning schedule, as well as total cleaning. They stated that cleanliness should be a cultural norm. ‘’It is crucial to keep the hospital clean. To keep it going, everyone in the service is responsible for the mother's hygiene and not just the nurse’’ . IDI, Doctor, male, 37 years. Participants recommend providing clean water and soap for clients, along with outlining plans for bathing and bed making. They also suggest requesting mothers to come with their own hygienic supplies. 1.7 Equality care Service providers echoed that they provide equal care to all women, accepting them as they are without considering their socio-economic status. However, they reported that educated mothers understand things more simply and quickly than others. Participants questioned why previous findings on quantitative research conducted on mothers reported that mothers who delivered by caesarean section perceived as being more respected than those with a normal delivery. They pointed out that a caesarean section is performed by a team, whereas in a normal delivery, the mother is cared for by one or two persons. Thus, a mother may simply be biased, thinking that being cared for by a team is a sign of respect. ‘’For mothers who delivered by caesarian section; it's not a procedure that is performed by one healthcare provider. There are many, anesthesiologists, and obstetricians... there are many. In the operating room you find 4 to 5 people around you; this leads mother to think she is really cared for. But for vaginal delivery, there is only one person. “ FGD 2 In addition, they reported that in a cesarean section, the mother is given pain medication before, during, and after the procedure. In contrast, during vaginal delivery, the mother may struggle to cope with labor pain, leading to feelings of giving up, and sometimes mothers are mistreated in the effort to save the baby. 2. Professionalism compliance HCPs reported that their profession is a vocation and not like other professions. The love for the profession and respect for the oath are considered very important. Midwives reported that they relate their practices to what they learned in school. Furthermore, they learn from their experiences and avoid repeating past incidents. HCPs reported conducting client interviews and sharing client feedback with the staff. In meetings, the unity manager shares what is appreciated and critiques themselves. Employees know they should provide good services and be safe and calm in difficult situations. There is a culture of prioritization involving triage and starting with emergency cases. The challenge is a large number of clients and an insufficient workforce. There is a culture of listening to the client's complaints and making incident reports if they occur. ‘’We have established a culture among the staff that if our clients complain, you should not tell them that I can't help them, but you should listen to them, help them and give them advice” IDI, matron, 34 years 2.1 Motivated staff The matron reported that in order to motivate the team, they have established solidarity and social activities among the maternity team, midwives organize and attend social events of their colleagues, such as wedding ceremonies and birth events, and even visit colleagues in difficult moments. They added that what keeps them in their career is the feeling that they are saving people, and when mothers are happy, HCPs also become happy (a positive cycle). Participants suggested ways to motivate the staff, such as providing tea or even food to decrease work stress and burnout, as well as rewarding and appreciating the best employees in public. “When an employee does something good, you should praise her. Appreciating her is one thing, don't give her money because she is being paid, but showing her that you value what she did, this is also a motivation’’ . IDI, matron, 33 years 2.2 Teamwork The participants reported that teamwork is key and everyone in a team should be aware of their limitations and ask for help so that the mothers can achieve better outcomes and happiness. The task allocation schedule exercise is flexible, considering every staff member's issues without compromising the work. They advised if the health personnel don't feel well, it's better to communicate their feelings to their colleagues, and the staff should be attentive to those feelings to prevent any negative mood from affecting the mothers. “There are times when a midwife comes with problems. We should know who has a problem so that it can disturb the client's feelings, and we assign her to a place where she will not meet people’’ FGD 4 2.3 Continuous development Some midwives have gotten RMC training. One matron requested to have continuous professional courses at the hospital or at school. The training can be organized by the hospital or the Ministry of Health. Midwives need the opportunity to receive full scholarships to upgrade their educational level. “Here we have midwives who have been around for more than 15 years, and the healthcare system is being updated. Therefore, for mothers to receive quality care, it is essential to increase their knowledge.” IDI, matron, male,27 years 2.4 Quality work provision Participants reported that accountability is needed to sustain the quality of care. HCPs emphasized their pride is getting a healthy baby and a healthy mother. Planning for pregnancy was highlighted as a key to a successful outcome. Participants appreciated that neonatology rooms are available. Participants stressed the importance of avoiding carelessness, implementing strict labor monitoring, following the partograph, and complying with accreditation guidelines. Hard copies of protocols are available and HCPs are able to check online for national guidelines when they encounter challenges. These hospitals are in the process of accreditation to improve the quality of services. Some HCPs reported that they have regular meetings and audits to monitor and evaluate the standards. Employee evaluation has a significant impact on RMC provision. Every staff member receives a bonus based on competence-based performance (PBF), this motivates them to make an effort to work better. In hospitals, a survey on customer satisfaction is usually conducted, and recommendations based on the feedback are implemented. The project on quality improvement conducts evaluations every month. Protocols from the Ministry of Health are provided to every staff member. “When a mother gives birth to a healthy baby, and all of them are healthy, it is our pride as midwives, and it is also the pride of the country and the community in general”. FGD 3 In the past, some the hospital building did not have immediate access to macadamized road. The HCPs appreciate the building of macadamized road to their hospital “The road to this hospital was damaged, the cars used to get there were going to stack, and you found mothers complaining about it, but now the road is macadamized and enjoyable, and mothers feel respected.’’ FGD1 2.5 Community trust The participants believe that when they provide friendly service, mothers will share their positive experiences repeatedly within the community, thereby restoring trust in the community. “To gain community trust, we need a good outcome. Whenever you treat a woman with empathy, she will be the one to preach to others in the whole village. The one you treat well is the one who is going to change the population's mind’’ . IDI, doctor, male, 30 years There is a way to handle incidence of disrespect. “We have a program called the patient's voice, as well as visit the community and listen to feedback and recommendations’’. IDI, matron, male, 32 years 3. RMC encounters Labor pain medications are not yet available at all study sites. At the national level, protocols on labor pain medication are available but are only followed in tertiary hospitals in city. However, doctors in our study sites may not have the necessary skills to administer subdural anesthesia. In the postpartum period, minor painkillers like paracetamol and tramadol are administered. ‘’There are labour pain management protocols that have been developed at national level, but the nature of the hospital does not allow doctors to give labour painkiller drugs. Still, in our hospitals in Rwanda, we do not have enough doctors to care for the mother who has been given subdural anesthesia.” IDI, doctor, male, 35 years Participants reported that mothers are taking traditional medications which can leads to maternal and neonatal adverse outcomes. “Although it is not scientifically proven, we do not know what key ingredients are included in traditional medicines, sometimes you find that mothers are saying they help them, but they can also harm the condition of the baby in the womb.’’ IDI, doctor, male, 35 years Among reported RMC hindrances are insufficient labour wards, sometimes birth companions have fear seeing mothers screaming and don’t understand it. Most of maternity services have insufficient doctors and midwives, overloaded clients, insufficient equipment like 1CTG per 20 clients, lack of private room. In addition, available rooms are built in close proximity so that one person can hear one another; which hinder confidentiality, privacy and staying with birth companion. Insufficient beds where 2 or 3 mothers share one bed have been reported. One matron reported that there is staffing plan that shows the workload and they advocate to the Ministry of Health to increase the number of midwives. Service providers argue that mostly it is difficult to explain to the mothers and meet their level of understanding because many of mothers are uneducated. Providers from one hospital reported that obtaining clean water in the hospital is a problem but the issue has been reported to the hospital management to find a solution. Participants argue that the service can be good but client satisfaction depend on someone’s perceptions and personality. 4. RMC sustenance To sustain RMC, participants emphasized to use empathy approach towards mother should be a cultural norm. They added that having self-confidence, regular supervision (with the clinical director overseeing technical staff and correcting any errors), being reminded of fundamental principles of human rights, and avoiding rushing in care provision, to avoid being busy on computers. The monitoring system should be reinforced, with regular quality improvement meetings and RMC refresher trainings. Workload adjustment, educating mothers on their rights at the entrance of the hospital. Equipment should be requested on time, and collaboration with maintenance services is crucial. Health education should be conducted during antenatal care and at the community level to discourage the use of traditional medicine. Close monitoring during labor is essential, and increasing the number of workers and implementing shifts is recommended. Advocacy for motivation, such as salary increases or bonuses, as well as providing refreshments (tea breaks), is encouraged. There is a suggestion to increase the capacity of customer care services to be available 24/7. Participants also recommend organizing study trips to hospitals with high standards. “I feel what could be done, there is something called a school trip, I felt that we can learn from other hospital by visiting to the model place …We can learn how is their maternity, and how they do maintain the privacy of their patients…. I feel that we should learn from others to see how they do it as said Kinyarwanda proverb "a bird that does not fly does not know where the corn is ripe". FGD 4 To enable mothers to have to experience normal delivery, mothers are encouraged to attend antenatal consultation, performing physical exercises, to attend the hospital early. In addition, participants emphasized that the mother should be called by name. ‘’If you call the mother by name when she sees you call her by her name; it makes her feel comfortable’’ . FGD 1 Participants reported that, to gain community trust, they should be diligent and provide better service for better outcomes. The community should be informed about the services that are typically provided and those beyond their capacity. Additionally, HCPs should focus on positive changes, maintain positive aspects, learn from others, and constantly self-evaluate. HCPs should improve patient education and receive mothers well, as the client's first impression can play a role in regaining community trust. HCPs advised the hospital management to find out the community's perceptions of hospital services Many participants suggest increasing the staff, especially midwives, for performing normal deliveries, training newcomers, and improving the buildings, particularly phasing out the use of curtains. Some participants suggested using soundproofing to maintain the confidentiality of mothers. They recommended using rooms with soundproofing instead of curtains to ensure patient information cannot be overheard by other patients. They recommended monitoring the mother adequately and teaching her how to behave, position, and breathe during labor. It is suggested to procure enough equipment like CTG machines based on the number of clients, ensure an adequate number of beds, and supervise cleanliness in the hospital. Participants emphasize doing the work with a heart of love, reinforcing awareness of women's rights on radio or other platforms, and conducting RMC sensitization in the community. They advise to avoid retaining mothers in the hospital when they fail to clear the medical bill. Discussion In the context of this paper, the participants’ perceptions, highlight the importance of ensuring women-centered care, with compassion, privacy, confidentiality, the right to information, autonomy, effective communication, holistic care with family involvement, personal hygiene, and equal care. This aligns with the experience of care dimensions established by the WHO in 2018 and quality of care framework for maternal and newborn health ( 40 ). Shakibazadeh et al. ( 34 ) identified twelve domains of RMC, one of which emphasizes providing woman-centered care. A study employing Appreciative Inquiry (AI) conducted in Tanzania and Malawi reported that compassionate healthcare provider-woman interactions involve a warm reception, polite language, timely and pertinent care, as well as the exchange of relevant information ( 25 ). The utilization of Patient-Centered Care leads to positively childbirth experience and positive outcomes for both mothers and newborns ( 13 ). Moreover, to achieve significant reduction in maternal mortality, there should be a strong focus on making services truly woman-centered ( 1 ). Surprisingly, in a study conducted in Ghana, midwife students attempted to justify mistreatment, they argue that if a mother in labor is uncooperative, in order to avoid adverse outcomes, the midwives have a reason to beat her a bit to ensure she complies with instructions ( 32 ). Studies highlighted the need to raise awareness among care providers about RMC standards by enhancing client-provider communication, monitoring practices, and strengthening accountability mechanisms for health workers ( 13 ) ( 4 ). Participants also revealed that compliance with their profession is key to achieving RMC. Professional compliance becomes possible when staff work as a team. Studies argue that teamwork among all HCPs is associated with improvements in respectful care ( 1 ) ( 2 ). The positive attitude of HCPs is crucial, even in attracting mothers to utilize health facility childbirth ( 25 ) ( 37 ). Supportive leadership is key to successful RMC practices ( 25 ) ( 19 ) ( 9 ) ( 10 ) A conducive environment with the necessary equipment and adequate physical setting leads to positive childbirth experiences ( 25 ) ( 22 ) ( 20 ). Improving infrastructure, may be perceived as challenging to implement and could take time. However, HCPs can work with existing resources, such as using partitions and curtains, to maintain the privacy of mothers ( 25 ). Though the rights and responsibilities of clients are displayed on the hospital wall, these rights are general patient rights and are not specific to women and newborns. There is a need to post the RMC charter on the maternity wall as a strategy for creating awareness of RMC among service users. In some hospitals from the study sites, there is a culture of systematically obliging every woman in labor to wear a diaper to prevent attracting or spreading infection and for individual hygiene. However, some women resist, fearing that their babies can die inside. To alleviate their anxiety, it is crucial to explain to the mothers the importance and reassure them that there is no harm in wearing a diaper before giving birth. Traditionally, Rwandan women don't even put underwear during labor because they believe it can delay the descent of the baby, leading to prolonged labor or the baby being asphyxiated inside. To build community trust, participants recommended improving services and explaining available services based on the hospital level. An interventional study conducted in Kenya suggested using open maternity days to engage the community in maternity services ( 37 ). It is essential to involve the Rwandan community in maternity service activities during community work, such as building and cleaning health facilities, to foster a sense of belonging and ownership. The community should also be educated about the rights of women and newborns. Though the purpose of this study was to explore the positive aspects of what can be done, the participants also narrated the challenges that hinder the RMC provision. They reported several issues affecting RMC, including insufficient labor wards, sharing of beds, inadequate birth companionship, non-use of labor painkiller medicines in all health facilities, staff shortages, client overload, and a lack of equipment. The absence of private rooms hampers confidentiality, privacy, and the ability to stay with a birth companion ( 11 ). Challenges in delivering RMC included logistical difficulties in ensuring privacy, lack of mobility during labor, high workload, absence of alternative birthing positions, negative attitudes from certain midwives, and language barriers ( 11 ) ( 18 ) Supportive leadership which conducts overseeing the staff, supervision, mentorship was also recommended. Evidence reported that the lack of RMC is not only an individual issue ( 37 ) ( 22 ) ( 17 ). According to Kujawski et al. ( 22 ), RMC is not attainable through a straightforward single technical solution. Instead, eliminating disrespect and abuse necessitates individual behavior change, organizational and systemic adjustments, and ultimately, a more profound societal transformation. Therefore, achieving RMC is a process that requires evidence-based strategies to achieve the deliverables and commitments that health care practitioners are called and declare upon. These strategies include the establishment of national laws and policy standards for RMC, adherence to human rights and ethical principles, and the presence of effective governance and leadership. Additionally, contributors encompass having an ample number of HCPs trained in RMC, ensuring the availability of sufficient drugs, equipment, and technology, maintaining a functional information system, and securing financing, such as health insurance. It is essential to have the well-equipped health facilities with adequate infrastructure, delivering care with accountability and supervision. Individual and community involvement is crucial, with mothers empowered to autonomously demand RMC, and community which is aware of RMC principles. Furthermore, a complaints redress mechanism should be implemented ( 37 ) ( 17 ). It was proved that multiple interventions are more effective in improving RMC compared to a single intervention ( 19 ) ( 10 ) ( 9 ) ( 11 ). Respect plays a fundamental role in Rwandan culture, influencing various traditional social interactions. Integrating this culture of respect into the journey of childbirth is essential to enhance the contributions of Rwandan women and mothers to the nation-building process. RMC is in line with Rwandan culture of respecting everyone especially the pregnant women. Rwanda is fostering a culture that values and invests in the well-being of its women and mothers. However, it should be noted that predictors of positive or negative RMC experiences can differ across countries, settings, and cultures. The methodology we used in this study is appropriate to RMC; appreciative inquiry promotes positive thinking, uplifts and sustains existing best practices rather than struggling to repair harms ( 25 ). The AI method brings suitable solutions for countries with resource-constrained health settings like Rwanda because it fosters a culture of maintaining positive traits, working with what is available in the field, and appreciating what has been achieved instead of perpetuating blame ( 25 ) ( 35 ). Rwanda has made progress towards universal health coverage. Presently, 91% of Rwandans have medical health insurance ( 6 ), resulting in a significant decrease in post-childbirth hospital detentions due to unpaid bills. (RMC is now integrated into Basic Emergency Obstetric and Newborn Care (BEmONC), with healthcare providers receiving RMC training and mentorship through programs such as the Maternal and Child Survival Program ( 24 ) and the More Happy Birthdays project ( 26 ). These initiatives, conducted in collaboration with the Rwanda Association of Midwives and the Ministry of Health, represent recent efforts to enhance RMC documentation ( 12 ). 5.Conclusion and recommendations : The pursuit of a RMC high standard is an ongoing journey, and some steps have been taken to improve RMC in Rwanda. Therefore, in the ongoing process of achieving RMC, it is possible to enhance the childbirth experience by working with existing resources, continuously improving over time, and sustaining the achievements until reaching the RMC standard. In this study, the recommended actions to sustain RMC include promoting women-centered care, improving healthcare provider personal attitudes, abiding on the profession, building community trust, ensuring a conducive environment in health facilities, and leadership should be actively involved and provide support. Strengths and Limitations One strength of this study is the utilization of the Appreciative Inquiry approach, which provided a positive way forward by shifting from problem-focused to solution-seeking perspectives. The recommendations yield from this study are applied to low resources health settings and envisage to improve RMC and working with the current available resources. However, a limitation is that the findings are solely based on the respective participants' views. Declarations Ethics approval and consent to participate. All methods were carried out in accordance with relevant guidelines and regulations. The study protocols were approved by the University of Rwanda Institutional Review Board (Approval Notice: No 070/CMHS-IRB/2023, the National Health Research Committee (NHRC) of the Ministry of Health (MoH) of Rwanda (Reference: NHRC/2022/PROT/003), and the Human Ethical Research Committee (HREC) from Wits University (Approval Notice: No M220265). Permission was also obtained from the study sites. Informed consent was obtained from all participants involved in the study. None of the participants were minors. Consent for publication : Not applicable Availability of data and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files]. The datasets generated and analysed during the current study are available in the Supplementary Data1_ Excel output from Invivo 12 analysis of health care providers’ interviews and focus groups repository Competing interests : None Funding : This research was funded by CARTA and University of Rwanda (UR)/Swedish International Development Cooperation Agency (SIDA) program. AM was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the Fellow. Authors’ contributions Alice Muhayimana: Conceptualization, Methodology, Data collection, Data transcribing, Formal analysis, Writing - Original draft preparation and editing. Irene Josephine Kearns: Conceptualization, Supervision, Methodology, Formal Analysis, Writing - Original draft preparation, reviewing & editing. Acknowledgments We extend our gratitude to the healthcare providers who took part in this research. We also express our appreciation to the hospital managers at the research sites. Furthermore, our sincere thanks go to our collaborators, including University of Witwatersrand, CARTA and facilitators, as well as the UR/SIDA program, for their generous financial support for this endeavor, in addition to the collaboration with Rwanda Biomedical Center and Rwanda Ministry of Health. References Bante, A., Teji, K., Seyoum, B., Mersha, A. 2020. Respectful maternity care and associated factors among women who delivered at Harar hospitals, eastern Ethiopia: a cross-sectional study. BMC Pregnancy and Childbirth, 20 (1), 86. https://doi.org/10.1186/s12884-020-2757-x Bohren, M.A., Tunçalp, Ö., Miller, S. 2020. Transforming intrapartum care: respectful maternity care. Best Practice & Research Clinical Obstetrics & Gynaecology, 67, 113–126. DOI: 10.1016/j.bpobgyn.2020.02.005 Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth. Boston: USAID-TRAction Project, Harvard School of Public Health. 2010 Sep 20:3. Bulto, G. A., Demissie, D. B., & Tulu, A. S. (2020). Respectful maternity care during labor and childbirth and associated factors among women who gave birth at health institutions in the West Shewa zone, Oromia region, Central Ethiopia. BMC Pregnancy and Childbirth , 20 (1), 1-12. Callister LC, Edwards JE. Sustainable development goals and the ongoing process of reducing maternal mortality. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2017 May 1;46(3):e56-64 Collins, D., U. Saya, and T. Kunda. "The impact of community-based health insurance on access to care and equity in Rwanda." Medford (MA): Management Sciences for Health (2016). Cooperrider D, Whitney DD, Stavros J. The appreciative inquiry handbook: For leaders of change. Berrett-Koehler Publishers; 2008. Creswell JW, Poth CN. Qualitative inquiry and research design: Choosing among five approaches. Sage publications; 2016 Dec 19. Diamond-Smith, N., Lin, S., Peca, E., & Walker, D. (2022). A landscaping review of interventions to promote respectful maternal care in Africa: opportunities to advance innovation and accountability. Midwifery , 115 , 103488. Diamond-Smith, N., Walker, D., Afulani, P. A., Donnay, F., Peca, E., & Stanton, M. E. (2023). The Case for Using a Behavior Change Model to Design Interventions to Promote Respectful Maternal Care. Global Health: Science and Practice , 11 (1). Dzomeku, V.M., Mensah, A.B., Nakua, E.K., Agbadi, P., Okyere, J., Donkor, P., Lori, J.R. 2022. Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana. BMC Pregnancy and Childbirth, 22 (1), 1–5. DOI: https://doi.org/10.1186/s12884-022-04786-w East and Southern Africa Regional office (ESARO), Respectful Maternity Care, 2022, Johannesburg, South Africa Ferede, W.Y., Gudayu, T.W., Gessesse, D.N., Erega, B.B. 2022. Respectful maternity care and associated factors among mothers who gave birth at public health institutions in South Gondar Zone, Northwest Ethiopia 2021. Women’s Health, 18, doi: 10.1177/17455057221116505 Griggs DJ, Nilsson M, Stevance A, McCollum D. A guide to SDG interactions: from science to implementation. International Council for Science, Paris; 2017. Grove S. K, Gray, JR & Burns, N. 2015. Understanding Nursing Research: Building an evidence-Based Practice. 6th ed. China: Elsevier. Hajizadeh, K., Vaezi, M., Meedya, S., Mohammad Alizadeh Charandabi, S., Mirghafourvand, M. 2020. Respectful maternity care and its relationship with childbirth experience in Iranian women: a prospective cohort study. BMC Pregnancy and Childbirth, 20 (1), 1–8. DOI: https://doi.org/10.1186/s12884-020-03118-0 Hameed W, Khan B, Siddiqi S, Asim M, Avan BI. Health system bottlenecks hindering provision of supportive and dignified maternity care in public health facilities. PLOS Global Public Health. 2022 Jul 8;2(7):e0000550. Jolivet, R. R., Gausman, J., Kapoor, N., Langer, A., Sharma, J., & Semrau, K. E. (2021). Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review. Reproductive health , 18 , 1-15. Kasaye, H., Sheehy, A., Scarf, V., & Baird, K. (2023). The roles of multi-component interventions in reducing mistreatment of women and enhancing respectful maternity care: a systematic review. BMC Pregnancy and Childbirth , 23 (1), 305 Kitaw, M., Tessema, M. 2019. Respectful maternity care and associated factors among mothers in the immediate postpartum period, in public health facilities of Addis Ababa, Ethiopia, 2018. International Journal of Pregnancy and Childbirth, 5 (1), 10–17. DOI: 10.15406/ipcb.2019.05.00140 Korstjens I, Moser A. Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing. European Journal of General Practice. 2018 Jan 1;24(1):120-4. Kujawski SA, Freedman LP, Ramsey K, et al . Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga region, Tanzania: a comparative before-and-after study. PLoS Med 2017;14:e1002341. Lincoln, Y. S., & Guba, E. G.But is it rigorous? trustworthiness and authenticity in naturalistic evaluation. New Directions for Evaluation , 1986 (30), 73–84. https://doi.org/10.1002/ev.223 Maternal and Child Survival Program (MCSP) Rwanda Technical Brief:Maternal Health, 2017 accessed on https://pdf.usaid.gov/pdf_docs/PA00SVRQ.pdf Mdoe, P., Mills, T.A., Chasweka, R., Nsemwa, L., Petross, C., Laisser, R., Chimwaza, A., Lavender, T. 2021. Lay and healthcare providers’ experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: an Appreciative Inquiry. BMJ Open, 11 (9), e046248. DOI: 10.1136/bmjopen-2020-046248 More Happy Birthdays project, 2022 accessed on https://internationalmidwives.org/assets/files/project-files/2022/09/20220925-mhb-project-final-report.pdf Muhayimana A, Kearns IJ, Gishoma D, Tengera O, Uhawenimana TC. Experiences and perceptions of respectful maternity care during childbirth in health facilities of Eastern province of Rwanda: An Appreciative Inquiry (unpublished) Mukamurigo J, Dencker A, Ntaganira J, Berg M. The meaning of a poor childbirth experience–a qualitative phenomenological study with women in Rwanda. PloS one. 2017 Dec 8;12(12):e0189371. Ndirima, Z., Neuhann, F., & Beiersmann, C. (2018). Listening to their voices: understanding rural women’s perceptions of good delivery care at the Mibilizi District Hospital in Rwanda. BMC women's health , 18 , 1-11. Nishimwe A, Conco DN, Nyssen M, Ibisomi L. Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda: a qualitative study. BMC nursing. 2022 Jan 4;21(1):9. Polit D, Beck C. Essentials of nursing research: Appraising evidence for nursing practice. Lippincott Williams & Wilkins; 2020 Dec 30. Rominski, S. D., Lori, J., Nakua, E., Dzomeku, V., & Moyer, C. A. (2017). When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out: justification of disrespectful and abusive care during childbirth among midwifery students in Ghana. Health policy and planning , 32 (2), 215-224. Rosen HE, Lynam PF, Carr C, Reis V, Ricca J, Bazant ES, Bartlett LA, Quality of Maternal and Newborn Care Study Group of the Maternal and Child Health Integrated Program. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC pregnancy and childbirth. 2015 Dec;15:1-1. Shakibazadeh, E., Namadian, M., Bohren, M.A., Vogel, J.P., Rashidian, A., Nogueira Pileggi, V., Madeira, S., Leathersich, S., Tunçalp, Ӧ., Oladapo, O.T., Souza, J.P. 2018. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG: An International Journal of Obstetrics & Gynaecology, 125 (8), 932–942. doi: 10.1111/1471-0528.15015. Epub 2017 Dec 8. Stavros JM, Godwin LN, Cooperrider DL. Appreciative inquiry: Organization development and the strengths revolution. Practicing organization development: Leading transformation and change. 2015 Geneva, Switzerland. ISBN 978-92-4-155021-5 The New Times, Rwanda.Accelerating progress in achieving respectful maternity care in Rwanda, 2023 https://www.newtimes.co.rw/article/12755/opinions/accelerating-progress-in-achieving-respectful-maternity-care-in-rwanda [accessed on 23 December 2023) Warren CE, Ndwiga C, Sripad P, Medich M, Njeru A, Maranga A, Odhiambo G, Abuya T. Sowing the seeds of transformative practice to actualize women’s rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research. BMC women's health. 2017 Dec;17(1):1-8. White Ribbon Alliance. 2019. RMC charter: universal rights of mothers and newborns. https://whiteribbonalliance.org/wp-content/uploads/2022/05/WRA_RMC_Charter_FINAL.pdf World Health Organization. 2018. WHO recommendations: Intrapartum care for a positive childbirth experience. WHO, Afulani, P.A., Phillips, B., Aborigo, R.A., Moyer, C.A. 2019. Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India. The Lancet Global Health, 7 (1), e96-e109. https://doi.org/10.1016/S2214-109X(18)30403-0 World Health Organization; Quality of improvement of maternal and newborn care quality, World Health Organization, 2016 Dhakal, P., Creedy, D.K., Gamble, J., Newnham, E., McInnes, R. 2022. Educational interventions to promote respectful maternity care: a mixed-methods systematic review. Nurse Education in Practice, 103317. DOI: 10.1016/j.nepr.2022.103317 Additional Declarations No competing interests reported. Supplementary Files SupplementaryData1ExceloutputfromInvivo12analysisofhealthcareprovidersinterviewsandfocusgroupsrepository.xlsx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 05 Jan, 2024 Editor assigned by journal 04 Jan, 2024 Submission checks completed at journal 04 Jan, 2024 First submitted to journal 30 Dec, 2023 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 Advisory Board 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-3824494","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":265362883,"identity":"24dfce0c-e68f-4558-8da8-d7aa199daa70","order_by":0,"name":"Alice Muhayimana","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Alice","middleName":"","lastName":"Muhayimana","suffix":""},{"id":265362884,"identity":"629f7180-7fc8-4590-967e-508d8c208035","order_by":1,"name":"Irene Kearns","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBACNgiVAKE+MEiQqIVxBoMEEXqQtTDzMBBhDZ/04WMPPjCkyfHPPnv4s22bRZ18A/PDDwx/7HA7jC8t3XAGQ46xxLm8NOncNgkJgwNsxhIMPMm4tfDwmEnzMFQkNpzhMWPO3QbUwsBgBnQfMx4t/N+k/zBU1M8/w2P82RKoRb6B/RsDg0E9PlvYpBkYchIMzvAYSDMCtTAc4AHaknAYjxY2M8kegzTDjUCHSfb+k5DccJinWCLhwHGcWuR7mJ9J/KhIlpcDOuzDjzN1/PLt7Rs/fPhTjVMLBBggc0AeTyCgYRSMglEwCkYBfgAAtEFAzex+UoMAAAAASUVORK5CYII=","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":true,"prefix":"","firstName":"Irene","middleName":"","lastName":"Kearns","suffix":""}],"badges":[],"createdAt":"2023-12-30 16:44:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3824494/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3824494/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49302082,"identity":"bc06698f-4685-4e74-bc3d-320ec801e15e","added_by":"auto","created_at":"2024-01-08 09:58:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":562435,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3824494/v1/32b6e942-78bc-4ef0-b5ad-92fb90d26512.pdf"},{"id":49301757,"identity":"c4eb5c34-989c-4458-98e3-38a589b54572","added_by":"auto","created_at":"2024-01-08 09:50:58","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":52435,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryData1ExceloutputfromInvivo12analysisofhealthcareprovidersinterviewsandfocusgroupsrepository.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3824494/v1/04f47ba13b3e48c6c1ac706d.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healthcare Providers' Perspectives on Sustaining Respectful Maternity Care Appreciated by Mothers, in Five Hospitals of Rwanda","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIn the era of striving to achieve the Sustainable Development Goals (SDGs), countries worldwide, including Rwanda, aim to meet all goals and targets by 2030, employing various strategies. This study specifically focuses on one target of SDG number 3: to end all preventable deaths of maternal and newborns (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and one target of SDG number 5: to eliminate all forms of violence against women and girls (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChildbirth, a significant human experience, demands respect. The intrapartum and immediate postpartum period pose a high risk for both mother and newborn, necessitating high-quality care (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). White Ribbon Alliance (WRA) defined Respectful maternity care (RMC) as a human right of every woman and her baby of being treated with care, respect and dignity, free from harm, and to maintain absolute liberty and autonomy (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Therefore, RMC is not an option, it is a basic human right. World Health Organization (WHO) in 2018 stated that RMC extends beyond the mere prevention of maternal morbidity and death. It emphasizes the need of ensuring that women have a pleasant delivery experience, which entails being treated with utmost respect and dignity (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In 2018, WHO shifted its focus towards ensuring a positive childbirth experience, emphasizing its importance (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMistreatment towards mothers during childbirth contributes to the poor quality of maternity care they receive (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Studies argue that Disrespect and Abuse (D\u0026amp;A) can inflict long-term psychological damage and emotional trauma, diminishing women's confidence and self-esteem (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Being disrespected may lead to feelings of shame, sorrow, insecurity, distrust in healthcare staff, a sense of powerlessness, and reluctance to seek help (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Memories of labor and delivery experiences persist throughout a woman's lifetime and are often shared with others (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Disrespectful and abusive care instils fear of future utilization of maternity services, reducing their use, which, in turn, hinders safe motherhood and contributes to increased adverse maternal and neonatal outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). D\u0026amp;A is a violation of fundamental human rights (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRwanda has made significant strides in maternal and neonatal health, achieving Millennium Development Goals through initiatives like skilled birth attendants, family planning, and Community Health Workers (CHWs) since 2009. CHWs play a pivotal role in promoting maternal and newborn care at the household level. The introduction of RapidSMS technology in 2010 synchronized health systems, and increased ambulance services improved transfer of laboring pregnant women to health facilities. Mandatory health insurance coverage since 2008, with 91% coverage, ensures access to healthcare (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Rwanda's notable progress in prioritizing women's rights indeed, Rwanda has made significant strides in promoting gender equality, particularly in political representation. The country has surpassed many others in terms of the percentage of women in parliamentary positions, showcasing a commitment to empowering women at various levels of society. Ultimately, this commitment to respect and gender equality contributes to the overall development and progress of the nation (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). It sets a positive example for other countries and highlights the idea that empowering women is not only a matter of rights but also a strategic investment in the social and economic prosperity of the nation.\u003c/p\u003e \u003cp\u003eThe absence of overt disrespect or abuse during childbirth doesn't guarantee the presence of RMC practices; for instance, the absence of physical abuse doesn't necessarily indicate the existence of compassionate and positive care behaviors (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). RMC and mistreatment during childbirth represent opposite ends of a spectrum. Research indicates that women and newborns can experience a mix of both positive RMC practices and negative mistreatment behaviors within this range (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Providing RMC plays a crucial role in enhancing the quality and utilization of maternity services (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Advocating for RMC is essential for advancing the Sustainable Development Goals (SDGs), particularly in achieving the targets of eliminating preventable maternal and neonatal deaths and ending all forms of violence against women (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Although in 2018, WHO launched a shift towards promoting positive childbirth experiences, appreciative RMC practices have largely remained under examined in academic literature (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), particularly in Rwanda, where very little is known about the perceptions of healthcare providers (HCPs) towards maternity care received by mothers.\u003c/p\u003e \u003cp\u003eLittle is known regarding perceptions of HCPs regarding RMC provision in Rwanda. Ndirima published findings on perceptions of maternity services at Mibilizi District Hospital in Rwanda's Western Province. The study involved rural women who had hospital births. The mothers commonly emphasized the need for respectful treatment in spaces which offering ample privacy, preferences regarding the gender of the birth attendant and the potential presence of their husbands during the childbirth process. Women in these remote areas make considerable effort to access healthcare facilities, with positive expectations, however the staff shortages pose obstacles (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Violations against the women\u0026rsquo;s dignity and respect were reported by women in labour in health facilities of Rwanda (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Women were slapped, verbally berated, humiliated, reprimanded, physically assaulted, insulted, abandoned, denied having birth companion and some were subjected to inappropriate and rough handling by healthcare providers. A significant number reported being shouted at for failing to follow instructions, and some were retained within hospitals due to unsettled bills (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In addition, women were being subjected to shouts and derogatory remarks from HCPs (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003e \u003cstrong\u003eResearch Design\u003c/strong\u003e \u003cp\u003eThis study employed an exploratory qualitative descriptive design, incorporating both Focus Group Discussions (FGD) and individual interviews as methods of data collection. The data collection approach utilized Appreciative Inquiry (AI), encouraging participants to reflect on their most positive experiences and perceptions and fostering a constructive and empowering perspective (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This study is a part of a doctoral project aimed at gaining insights into healthcare professional\u0026rsquo;s perceptions of RMC, with the overarching goal of developing strategies to promote RMC in Rwanda\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eAppreciative Inquiry approach\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAppreciative Inquiry embraces a 5D cycle that consists of the Definition, Discovery, Dream, Design and Destiny phases according to (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This 5D cycle allowed the participants to share their best moments of RMC and their expectations for RMC. In this study, the dream phase was only involved since the participants mainly narrated their views to sustain RMC.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDREAM phase\u003c/strong\u003e \u003cp\u003eThe Dream phase envisions a positive future, building on qualities discovered in the Discovery phase. It inspires discussions on favourable outcomes with the question, \"What will your ideal success (for RMC) look like?\" This phase fosters enthusiasm and collaborative vision, preparing for practical actions. In this study, the dream phase was based on the information gotten from the interviews and Focus groups, participants envisioned themselves how the maternity care services could operate at their best. Participants thought widely and holistically on the future they want. Through different varieties of imagining, the HCPs were asked to envisage and portrait RMC for the future (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSetting and population\u003c/strong\u003e \u003cp\u003eThe research was conducted at five hospitals located in the Eastern province of Rwanda. The study involved a sample of 50 healthcare providers (HCPs) working in maternity services, including medical doctors, midwives, and nurses. Ten in-depth interviews were conducted, involving five medical practitioners and five maternity unit supervisors (matrons) (\u003cem\u003erefer to Table\u0026nbsp;1\u003c/em\u003e). Additionally, five Focus Group Discussions were held, with the participation of 40 midwives and nurses working in maternity care (\u003cem\u003erefer to\u003c/em\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The investigation took place in May 2023. In general, participants were asked about their opinions on the findings reported by mothers in a previous study (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData collection\u003c/strong\u003e \u003cp\u003eThe interview was conducted in either Kinyarwanda or English, depending on the participant's preferred language. Demographic details were collected using a demographic questionnaire. In-depth information was elicited through probing questions. Participants were informed that mothers value compassionate care, and we asked for their suggestions on providing care free from harm and ill-treatment, as well as ways to demonstrate empathy. The interviewer emphasized that mothers appreciated autonomy and independence and asked the participants on how to achieve this. The interviewer asked the participants how they can grant mothers the decision-making liberty, allowing mothers to express their choices and preferences, and providing to them relevant information. Additionally, participants were informed that mothers value efficient care, and the interviewer sought their input on achieving this while sustaining dignified care, respect, and maintaining privacy and confidentiality.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFurthermore, HCPs were informed that mothers expressed a desire for a normal delivery, getting a healthy baby, and staying in a clean and tidy environment. The interview inquired about actions that can be taken to uphold these preferences. HCPs were also informed that mothers typically perceive HCPs who provide RMC as those who have love for people and passion for the profession, the interviewer asked how these aspects can be sustained. HCPs were then reminded that the community holds varying perspectives, both positive and negative, regarding the care women receive during labour and the birth process and they were asked to propose ways to regain the community's trust, along with interventions or actions from HCPs that would demonstrate RMC. Furthermore, HCPs were queried about the methods they view as respectful towards a woman in labour, from a healthcare provider's perspective, from hospital management, and within health facilities.\u003c/p\u003e \u003cp\u003e Following the conclusion of each interview, the researcher stressed the significance of subsequent communication via telephone calls to review the study findings and confirm their precise representation of participants' perceptions. Throughout the discussions, field notes were documented, and any fresh insights offered by participants were integrated into the analyzed data.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Analysis\u003c/strong\u003e \u003cp\u003eAfter each interview, the audio recordings were immediately transcribed word for word. Guided by the principal investigator, a research assistant translated these transcripts into English, simplifying the process and maintaining data integrity. To verify accuracy, these translations were then reverse translated into Kinyarwanda. The research employed an inductive thematic analysis approach, utilizing pertinent quotes to convey the findings. To deeply engage with the data, the researcher extensively reviewed the transcripts. The Nvivo 12 software played a crucial role in organizing the transcribed data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e The research team initiated the process by carefully listening to the recorded audio, ensuring the completeness and integrity of the data through cross-referencing with transcriptions. To gain a thorough understanding of the content, the team meticulously examined the transcripts (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). They utilized line-by-line coding to identify initial codes, which were then evaluated to establish categories based on similarities and differences in participants' responses. This process involved an iterative approach, with the team continually revisiting and refining the categories while cross-referencing with the original transcripts to ensure they accurately captured participants' genuine experiences and perspectives (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). This rigorous analysis led to the identification of primary themes. To validate these themes, select participants were consulted through a process known as member checking (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), ensuring that the themes resonated with their perceptions. Subsequently, an inductive thematic analysis was conducted, complemented by relevant quotes to comprehensively present the findings (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eTrustworthiness measure\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTo ensure the trustworthiness of the research findings in this study, the researcher adhered to the evaluative criteria for rigor in qualitative research. These criteria, as outlined by Lincoln and Guba (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and Grove and Burns (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), encompass credibility, dependability, confirmability, and transferability. Credibility, was ensured by deliberately selecting healthcare providers who met eligibility criteria, using open-ended questions in interviews to elicit detailed responses, and incorporating peer debriefing and member checking during data collection and analysis. Sharing transcripts for accuracy confirmation further enhanced credibility. Dependability was maintained by meticulously documenting decisions from research initiation to data analysis, creating a comprehensive audit trail. Data stability was also upheld through timely and consistent collection under similar conditions within a specific, relatively short period. Confirmability was maintained by relying solely on participant narratives for analysis, avoiding the imposition of the researcher's assumptions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Transferability was enhanced by providing a detailed description of the study's setting, sample, and investigated phenomenon using a well-structured interview guide.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;1. socio-demographic data from individual interviews\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThe majority (70%) of participants who took part in the interview were aged between 25 and 35. Among them, 80% were male, and 60% had experience of up to only five years\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1704707089.png\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cstrong\u003eTable 2. Demographic data from Focus Groups\u003c/strong\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eAbout half of the participants in the FGD fell within the age range of 31 to 35 (49.5%). The majority of participants were midwives (72.5%), and approximately half of them had accumulated one to five years of experience working in maternity services.\u003c/p\u003e\n\u003cdiv\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategories\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u0026ndash;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eExperience in maternity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 years and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eDuring thematic analysis, four themes and sub-themes emerged from the data:\u003c/p\u003e\n\u003cp\u003e1) \u003cstrong\u003eWomen centered care\u003c/strong\u003e \u003cem\u003ewith\u003c/em\u003e Compassionate care, Privacy and confidentiality maintenance, Information provision and liberty in decision making, Effective communication, Family involvement, Cleanliness of environment, Equality care. 2)\u003cstrong\u003eProfessionalism compliance\u003c/strong\u003e with Motivated staff, Teamwork, Continuous development, Quality work provision, Community trust. 3) \u003cstrong\u003eRMC encounters\u003c/strong\u003e \u003cstrong\u003e4)\u003c/strong\u003e \u003cstrong\u003eRMC sustenance\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e1. Women centered-care\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Compassionate care\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eHealthcare providers emphasized the importance of showing compassion to mothers. They stressed the need to put themselves in the client's shoes, treat the mother with empathy, reflect on ethical considerations, ensure her confidentiality, care for her with a good heart, make the mother feel relaxed, and show love and hope. They added that truly compassionate service would be achieved if a doctor treated every mother as if she were his/her own mother, wife, or sister. HCP reported that performing episiotomy without anesthesia is no longer exist.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;We need to have a heart of love and patience. In maternity, there is hard work, but we should have the heart to love people. So first we should strengthen love in ourselves and then have the gift of patience \u0026hellip; What we should do for the mothers to show them compassion first is to put ourselves in their position because if we put ourselves in their place.\u0026rdquo;\u003c/em\u003e \u003cb\u003eFGD1\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHCPs reported that mothers should understand that labor pain is natural and normal. HCPs support labor by reassuring the mothers, providing back massages, encouraging them to ambulate, and ensuring emotional well-being by offering comforting words. Service providers reported having insufficient knowledge about labor painkiller medications.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;An area where we have little knowledge is pain relief for the mother in labor. Pain management is not appropriately done but we teach them with the help of the Bible\u0026rdquo;.\u003c/em\u003e \u003cb\u003eFGD 5\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Privacy and confidentiality maintenance\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eHCPs stated that privacy is maintained by using curtains between beds, but they recommend the use of rooms because curtains sometimes do not ensure confidentiality. They reported that confidentiality is maintained during the handover process, labeling laboratory samples, and medical rounds, where they use medical terms, signs, and identifiers. In our study sites, participants reported that they no longer use printed files; instead, they utilize technology (such as open clinic) to store client information, with everyone having an individual password to log in. However, uncertainty about how to prevent maternity information from being accessed by providers from other services was expressed. On one study site, they reported that maternity is planned to be built with rooms therefore birth companionship will be possible.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Mainly, we care about the information we give to the mothers, their information is confidential, and we care about privacy\u0026rdquo;.\u003c/em\u003e \u003cb\u003eIDI, matron, female, 34 years\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Information provision and liberty in decision making\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMidwives reported that a mother has the right to request information and receive it, and she also has the right to make choices and express preferences. Participants reported that the rights and responsibility of the clients are written on the hospital wall. Some information for mother and neonatal care is being provided. Some participants mentioned that during reception, customer care services welcome the mothers, and allowed them to contact the representative of customer care services at any time during their stay in the hospital. Additionally, before being admitted, mothers are required to sign a consent form. Participants recommended that women's rights should be posted in a visible location for mothers to read.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There is a customer care representative of the hospital, her photo and number are available, they call her if they can't find the matron if a person has a problem and brings it to customer care, it is solved quickly\u003c/em\u003e\u0026rdquo;. \u003cb\u003eIDI, matron, female, 33 years\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Participants emphasized that mothers have the right to make their own decisions before receiving care. A mother may not have knowledge about her health; therefore, HCPs should first provide all information to the mother by explaining the pros and cons, allowing her to make a decision, and then sign the consent.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The care is central to women, not to us. She is the one who is going into the labor, she is the one who is going to bear any procedure that we are going to perform on her, so she has the right to refuse the treatment.\u0026rdquo;\u003c/em\u003e\u003cb\u003eIDI, doctor, male, 30 years.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants reported that a mother has the right to choose the treatment; for example, she has the right to opt for a cesarean section without medical indication. The decision-making process for a mother's treatment should be done as quickly as possible so that HCPs can take action without unnecessary delays.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Effective communication\u003c/h2\u003e \u003cp\u003eTo facilitate communication between clients, service providers and hospital management, they have a suggestion box for clients to share their ideas. After reading these suggestions, they can make decisions accordingly. Additionally, in some hospitals, there is a book where clients can submit any eventual complaints and measures can be implemented when there is evidence of disrespect.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere is a way to handle incidence of disrespect.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;When there is an incidence of disrespect; We have a quality book, whoever is found to have happened is approached and discussed and we can register her in the book and also resolve issue with the victim. If happens for the second time, the case is presented to the higher authorities for punishment\u0026rsquo;\u0026rsquo;\u003c/em\u003e \u003cb\u003eIDI, matron, female,33 years\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo handle disrespect issue, HCPs from one hospital reported that they manage it at their level or they refer to mental health services\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If a client is physically or psychologically harmed by a healthcare provider, the first is to prevent the spreading of information. In our measures, we have a team leader who must handle the problem and approach the family to find a solution. If it is beyond our control, we can use the mental health service to help us.\u0026rdquo;\u003c/em\u003e \u003cb\u003eIDI, matron, male,27years\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTo improve client-provider communication, providers should explain the labor process to the clients, giving them time to ask questions freely. Listening to them and providing feedback during this process helps to establish trust.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026rsquo;If you have confidence in explaining to the mother how things are going, and when you explain directly to her, she immediately trusts you\u0026rsquo;\u0026rsquo;\u003c/em\u003e. \u003cb\u003eIDI. Doctor, male, 37 years\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants advised HCPs first to introduce themselves to the mother. Taking time to read the client's file and talking with the client helps avoid harm. Explaining everything to the mother, including information on the baby's care, lab tests, and results, is crucial. Participants emphasized the importance of consented care, stating that service providers should explain everything they do and its significance, ensuring that mothers also understand. Providers should also clarify what is and is not allowed in the hospital, explaining their rights and responsibilities. They added that sometimes it is challenging to find time to provide all explanations to the mother.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;First we respect her rights. Respecting the right of the mother is to listen to her, to explain to her what she wants to know.\u0026rdquo;\u003c/em\u003e\u003cb\u003eFGD1\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e1.5 Family involvement\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eHCPs argue that a mother has the right to involve her family in her care process, and service providers help the mother to achieve that. Midwives used to involve a birth companion to assist in the mother's care. However, the infrastructure hinder the birth companion from staying with the mother during the second stage of labour and is a significant challenge.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The mother has the right to involve her family in the treatment when she wants, so that the male companion can come if she asks us, but when she doesn't ask, we have to treat her according to her rights.\u0026rdquo;\u003c/em\u003e \u003cb\u003eFGD 3\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e1.6 Cleanness\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eService providers argue that they encourage mothers to maintain personal hygiene. For infection prevention, HCPs used to request mothers to wear diapers during labor to prevent spreading of vaginal leakage, however, some mothers with traditional beliefs resist wearing those diapers. Providers ensure the cleanliness of beds and rooms and encourage mothers to maintain personal cleanliness as well. Cleanliness in the service is maintained, and there are cleaners specifically for the maternity ward and follow waste management measures. There is a daily cleaning schedule, as well as total cleaning. They stated that cleanliness should be a cultural norm.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;It is crucial to keep the hospital clean. To keep it going, everyone in the service is responsible for the mother's hygiene and not just the nurse\u0026rsquo;\u0026rsquo;\u003c/em\u003e. \u003cb\u003eIDI, Doctor, male, 37 years.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eParticipants recommend providing clean water and soap for clients, along with outlining plans for bathing and bed making. They also suggest requesting mothers to come with their own hygienic supplies.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e1.7 Equality care\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eService providers echoed that they provide equal care to all women, accepting them as they are without considering their socio-economic status. However, they reported that educated mothers understand things more simply and quickly than others. Participants questioned why previous findings on quantitative research conducted on mothers reported that mothers who delivered by caesarean section perceived as being more respected than those with a normal delivery. They pointed out that a caesarean section is performed by a team, whereas in a normal delivery, the mother is cared for by one or two persons. Thus, a mother may simply be biased, thinking that being cared for by a team is a sign of respect.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;For mothers who delivered by caesarian section; it's not a procedure that is performed by one healthcare provider. There are many, anesthesiologists, and obstetricians... there are many. In the operating room you find 4 to 5 people around you; this leads mother to think she is really cared for. But for vaginal delivery, there is only one person. \u0026ldquo;\u003c/em\u003e \u003cb\u003eFGD 2\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn addition, they reported that in a cesarean section, the mother is given pain medication before, during, and after the procedure. In contrast, during vaginal delivery, the mother may struggle to cope with labor pain, leading to feelings of giving up, and sometimes mothers are mistreated in the effort to save the baby.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2. Professionalism compliance\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eHCPs reported that their profession is a vocation and not like other professions. The love for the profession and respect for the oath are considered very important. Midwives reported that they relate their practices to what they learned in school. Furthermore, they learn from their experiences and avoid repeating past incidents. HCPs reported conducting client interviews and sharing client feedback with the staff. In meetings, the unity manager shares what is appreciated and critiques themselves. Employees know they should provide good services and be safe and calm in difficult situations. There is a culture of prioritization involving triage and starting with emergency cases. The challenge is a large number of clients and an insufficient workforce. There is a culture of listening to the client's complaints and making incident reports if they occur.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;We have established a culture among the staff that if our clients complain, you should not tell them that I can't help them, but you should listen to them, help them and give them advice\u0026rdquo;\u003c/em\u003e \u003cb\u003eIDI, matron, 34 years\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Motivated staff\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe matron reported that in order to motivate the team, they have established solidarity and social activities among the maternity team, midwives organize and attend social events of their colleagues, such as wedding ceremonies and birth events, and even visit colleagues in difficult moments. They added that what keeps them in their career is the feeling that they are saving people, and when mothers are happy, HCPs also become happy (a positive cycle). Participants suggested ways to motivate the staff, such as providing tea or even food to decrease work stress and burnout, as well as rewarding and appreciating the best employees in public.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When an employee does something good, you should praise her. Appreciating her is one thing, don't give her money because she is being paid, but showing her that you value what she did, this is also a motivation\u0026rsquo;\u0026rsquo;\u003c/em\u003e. \u003cb\u003eIDI, matron, 33 years\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Teamwork\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e The participants reported that teamwork is key and everyone in a team should be aware of their limitations and ask for help so that the mothers can achieve better outcomes and happiness. The task allocation schedule exercise is flexible, considering every staff member's issues without compromising the work. They advised if the health personnel don't feel well, it's better to communicate their feelings to their colleagues, and the staff should be attentive to those feelings to prevent any negative mood from affecting the mothers.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There are times when a midwife comes with problems. We should know who has a problem so that it can disturb the client's feelings, and we assign her to a place where she will not meet people\u0026rsquo;\u0026rsquo;\u003c/em\u003e\u003cb\u003eFGD 4\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Continuous development\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSome midwives have gotten RMC training. One matron requested to have continuous professional courses at the hospital or at school. The training can be organized by the hospital or the Ministry of Health. Midwives need the opportunity to receive full scholarships to upgrade their educational level.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Here we have midwives who have been around for more than 15 years, and the healthcare system is being updated. Therefore, for mothers to receive quality care, it is essential to increase their knowledge.\u0026rdquo;\u003c/em\u003e \u003cb\u003eIDI, matron, male,27 years\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Quality work provision\u003c/h2\u003e \u003cp\u003eParticipants reported that accountability is needed to sustain the quality of care. HCPs emphasized their pride is getting a healthy baby and a healthy mother. Planning for pregnancy was highlighted as a key to a successful outcome. Participants appreciated that neonatology rooms are available. Participants stressed the importance of avoiding carelessness, implementing strict labor monitoring, following the partograph, and complying with accreditation guidelines. Hard copies of protocols are available and HCPs are able to check online for national guidelines when they encounter challenges. These hospitals are in the process of accreditation to improve the quality of services. Some HCPs reported that they have regular meetings and audits to monitor and evaluate the standards. Employee evaluation has a significant impact on RMC provision. Every staff member receives a bonus based on competence-based performance (PBF), this motivates them to make an effort to work better.\u003c/p\u003e \u003cp\u003eIn hospitals, a survey on customer satisfaction is usually conducted, and recommendations based on the feedback are implemented. The project on quality improvement conducts evaluations every month. Protocols from the Ministry of Health are provided to every staff member.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When a mother gives birth to a healthy baby, and all of them are healthy, it is our pride as midwives, and it is also the pride of the country and the community in general\u0026rdquo;.\u003c/em\u003e \u003cb\u003eFGD 3\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn the past, some the hospital building did not have immediate access to macadamized road. The HCPs appreciate the building of macadamized road to their hospital\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The road to this hospital was damaged, the cars used to get there were going to stack, and you found mothers complaining about it, but now the road is macadamized and enjoyable, and mothers feel respected.\u0026rsquo;\u0026rsquo;\u003c/em\u003e \u003cb\u003eFGD1\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Community trust\u003c/h2\u003e \u003cp\u003eThe participants believe that when they provide friendly service, mothers will share their positive experiences repeatedly within the community, thereby restoring trust in the community.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;To gain community trust, we need a good outcome. Whenever you treat a woman with empathy, she will be the one to preach to others in the whole village. The one you treat well is the one who is going to change the population's mind\u0026rsquo;\u0026rsquo;\u003c/em\u003e. \u003cb\u003eIDI, doctor, male, 30 years\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere is a way to handle incidence of disrespect.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have a program called the patient's voice, as well as visit the community and listen to feedback and recommendations\u0026rsquo;\u0026rsquo;.\u003c/em\u003e \u003cb\u003eIDI, matron, male, 32 years\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e3. RMC encounters\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eLabor pain medications are not yet available at all study sites. At the national level, protocols on labor pain medication are available but are only followed in tertiary hospitals in city. However, doctors in our study sites may not have the necessary skills to administer subdural anesthesia. In the postpartum period, minor painkillers like paracetamol and tramadol are administered.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;There are labour pain management protocols that have been developed at national level, but the nature of the hospital does not allow doctors to give labour painkiller drugs. Still, in our hospitals in Rwanda, we do not have enough doctors to care for the mother who has been given subdural anesthesia.\u0026rdquo;\u003c/em\u003e \u003cb\u003eIDI, doctor, male, 35 years\u003c/b\u003e\u003c/p\u003e \u003cp\u003eParticipants reported that mothers are taking traditional medications which can leads to maternal and neonatal adverse outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Although it is not scientifically proven, we do not know what key ingredients are included in traditional medicines, sometimes you find that mothers are saying they help them, but they can also harm the condition of the baby in the womb.\u0026rsquo;\u0026rsquo;\u003c/em\u003e \u003cb\u003eIDI, doctor, male, 35 years\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong reported RMC hindrances are insufficient labour wards, sometimes birth companions have fear seeing mothers screaming and don\u0026rsquo;t understand it. Most of maternity services have insufficient doctors and midwives, overloaded clients, insufficient equipment like 1CTG per 20 clients, lack of private room. In addition, available rooms are built in close proximity so that one person can hear one another; which hinder confidentiality, privacy and staying with birth companion. Insufficient beds where 2 or 3 mothers share one bed have been reported. One matron reported that there is staffing plan that shows the workload and they advocate to the Ministry of Health to increase the number of midwives.\u003c/p\u003e \u003cp\u003eService providers argue that mostly it is difficult to explain to the mothers and meet their level of understanding because many of mothers are uneducated. Providers from one hospital reported that obtaining clean water in the hospital is a problem but the issue has been reported to the hospital management to find a solution. Participants argue that the service can be good but client satisfaction depend on someone\u0026rsquo;s perceptions and personality.\u003c/p\u003e\n\u003ch3\u003e4. RMC sustenance\u003c/h3\u003e\n\u003cp\u003eTo sustain RMC, participants emphasized to use empathy approach towards mother should be a cultural norm. They added that having self-confidence, regular supervision (with the clinical director overseeing technical staff and correcting any errors), being reminded of fundamental principles of human rights, and avoiding rushing in care provision, to avoid being busy on computers. The monitoring system should be reinforced, with regular quality improvement meetings and RMC refresher trainings. Workload adjustment, educating mothers on their rights at the entrance of the hospital. Equipment should be requested on time, and collaboration with maintenance services is crucial.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHealth education should be conducted during antenatal care and at the community level to discourage the use of traditional medicine. Close monitoring during labor is essential, and increasing the number of workers and implementing shifts is recommended. Advocacy for motivation, such as salary increases or bonuses, as well as providing refreshments (tea breaks), is encouraged. There is a suggestion to increase the capacity of customer care services to be available 24/7. Participants also recommend organizing study trips to hospitals with high standards.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I feel what could be done, there is something called a school trip, I felt that we can learn from other hospital by visiting to the model place \u0026hellip;We can learn how is their maternity, and how they do maintain the privacy of their patients\u0026hellip;. I feel that we should learn from others to see how they do it as said Kinyarwanda proverb \"a bird that does not fly does not know where the corn is ripe\".\u003c/em\u003e \u003cb\u003eFGD 4\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo enable mothers to have to experience normal delivery, mothers are encouraged to attend antenatal consultation, performing physical exercises, to attend the hospital early. In addition, participants emphasized that the mother should be called by name.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;If you call the mother by name when she sees you call her by her name; it makes her feel comfortable\u0026rsquo;\u0026rsquo;\u003c/em\u003e. \u003cb\u003eFGD 1\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants reported that, to gain community trust, they should be diligent and provide better service for better outcomes. The community should be informed about the services that are typically provided and those beyond their capacity. Additionally, HCPs should focus on positive changes, maintain positive aspects, learn from others, and constantly self-evaluate. HCPs should improve patient education and receive mothers well, as the client's first impression can play a role in regaining community trust. HCPs advised the hospital management to find out the community's perceptions of hospital services\u003c/p\u003e \u003cp\u003eMany participants suggest increasing the staff, especially midwives, for performing normal deliveries, training newcomers, and improving the buildings, particularly phasing out the use of curtains. Some participants suggested using soundproofing to maintain the confidentiality of mothers. They recommended using rooms with soundproofing instead of curtains to ensure patient information cannot be overheard by other patients.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey recommended monitoring the mother adequately and teaching her how to behave, position, and breathe during labor. It is suggested to procure enough equipment like CTG machines based on the number of clients, ensure an adequate number of beds, and supervise cleanliness in the hospital. Participants emphasize doing the work with a heart of love, reinforcing awareness of women's rights on radio or other platforms, and conducting RMC sensitization in the community. They advise to avoid retaining mothers in the hospital when they fail to clear the medical bill.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the context of this paper, the participants\u0026rsquo; perceptions, highlight the importance of ensuring women-centered care, with compassion, privacy, confidentiality, the right to information, autonomy, effective communication, holistic care with family involvement, personal hygiene, and equal care. This aligns with the experience of care dimensions established by the WHO in 2018 and quality of care framework for maternal and newborn health (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Shakibazadeh et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) identified twelve domains of RMC, one of which emphasizes providing woman-centered care. A study employing Appreciative Inquiry (AI) conducted in Tanzania and Malawi reported that compassionate healthcare provider-woman interactions involve a warm reception, polite language, timely and pertinent care, as well as the exchange of relevant information (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The utilization of Patient-Centered Care leads to positively childbirth experience and positive outcomes for both mothers and newborns (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Moreover, to achieve significant reduction in maternal mortality, there should be a strong focus on making services truly woman-centered (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Surprisingly, in a study conducted in Ghana, midwife students attempted to justify mistreatment, they argue that if a mother in labor is uncooperative, in order to avoid adverse outcomes, the midwives have a reason to beat her a bit to ensure she complies with instructions (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Studies highlighted the need to raise awareness among care providers about RMC standards by enhancing client-provider communication, monitoring practices, and strengthening accountability mechanisms for health workers (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants also revealed that compliance with their profession is key to achieving RMC. Professional compliance becomes possible when staff work as a team. Studies argue that teamwork among all HCPs is associated with improvements in respectful care (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The positive attitude of HCPs is crucial, even in attracting mothers to utilize health facility childbirth (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Supportive leadership is key to successful RMC practices (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA conducive environment with the necessary equipment and adequate physical setting leads to positive childbirth experiences (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Improving infrastructure, may be perceived as challenging to implement and could take time. However, HCPs can work with existing resources, such as using partitions and curtains, to maintain the privacy of mothers (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Though the rights and responsibilities of clients are displayed on the hospital wall, these rights are general patient rights and are not specific to women and newborns. There is a need to post the RMC charter on the maternity wall as a strategy for creating awareness of RMC among service users. In some hospitals from the study sites, there is a culture of systematically obliging every woman in labor to wear a diaper to prevent attracting or spreading infection and for individual hygiene. However, some women resist, fearing that their babies can die inside. To alleviate their anxiety, it is crucial to explain to the mothers the importance and reassure them that there is no harm in wearing a diaper before giving birth. Traditionally, Rwandan women don't even put underwear during labor because they believe it can delay the descent of the baby, leading to prolonged labor or the baby being asphyxiated inside.\u003c/p\u003e \u003cp\u003eTo build community trust, participants recommended improving services and explaining available services based on the hospital level. An interventional study conducted in Kenya suggested using open maternity days to engage the community in maternity services (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). It is essential to involve the Rwandan community in maternity service activities during community work, such as building and cleaning health facilities, to foster a sense of belonging and ownership. The community should also be educated about the rights of women and newborns.\u003c/p\u003e \u003cp\u003eThough the purpose of this study was to explore the positive aspects of what can be done, the participants also narrated the challenges that hinder the RMC provision. They reported several issues affecting RMC, including insufficient labor wards, sharing of beds, inadequate birth companionship, non-use of labor painkiller medicines in all health facilities, staff shortages, client overload, and a lack of equipment. The absence of private rooms hampers confidentiality, privacy, and the ability to stay with a birth companion (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Challenges in delivering RMC included logistical difficulties in ensuring privacy, lack of mobility during labor, high workload, absence of alternative birthing positions, negative attitudes from certain midwives, and language barriers (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSupportive leadership which conducts overseeing the staff, supervision, mentorship was also recommended. Evidence reported that the lack of RMC is not only an individual issue (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). According to Kujawski et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), RMC is not attainable through a straightforward single technical solution. Instead, eliminating disrespect and abuse necessitates individual behavior change, organizational and systemic adjustments, and ultimately, a more profound societal transformation. Therefore, achieving RMC is a process that requires evidence-based strategies to achieve the deliverables and commitments that health care practitioners are called and declare upon. These strategies include the establishment of national laws and policy standards for RMC, adherence to human rights and ethical principles, and the presence of effective governance and leadership. Additionally, contributors encompass having an ample number of HCPs trained in RMC, ensuring the availability of sufficient drugs, equipment, and technology, maintaining a functional information system, and securing financing, such as health insurance. It is essential to have the well-equipped health facilities with adequate infrastructure, delivering care with accountability and supervision. Individual and community involvement is crucial, with mothers empowered to autonomously demand RMC, and community which is aware of RMC principles. Furthermore, a complaints redress mechanism should be implemented (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). It was proved that multiple interventions are more effective in improving RMC compared to a single intervention (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRespect plays a fundamental role in Rwandan culture, influencing various traditional social interactions. Integrating this culture of respect into the journey of childbirth is essential to enhance the contributions of Rwandan women and mothers to the nation-building process. RMC is in line with Rwandan culture of respecting everyone especially the pregnant women. Rwanda is fostering a culture that values and invests in the well-being of its women and mothers. However, it should be noted that predictors of positive or negative RMC experiences can differ across countries, settings, and cultures. The methodology we used in this study is appropriate to RMC; appreciative inquiry promotes positive thinking, uplifts and sustains existing best practices rather than struggling to repair harms (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The AI method brings suitable solutions for countries with resource-constrained health settings like Rwanda because it fosters a culture of maintaining positive traits, working with what is available in the field, and appreciating what has been achieved instead of perpetuating blame (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRwanda has made progress towards universal health coverage. Presently, 91% of Rwandans have medical health insurance (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), resulting in a significant decrease in post-childbirth hospital detentions due to unpaid bills. (RMC is now integrated into Basic Emergency Obstetric and Newborn Care (BEmONC), with healthcare providers receiving RMC training and mentorship through programs such as the Maternal and Child Survival Program (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and the More Happy Birthdays project (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). These initiatives, conducted in collaboration with the Rwanda Association of Midwives and the Ministry of Health, represent recent efforts to enhance RMC documentation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e\u003cem\u003e5.Conclusion and recommendations\u003c/em\u003e: The pursuit of a RMC high standard is an ongoing journey, and some steps have been taken to improve RMC in Rwanda. Therefore, in the ongoing process of achieving RMC, it is possible to enhance the childbirth experience by working with existing resources, continuously improving over time, and sustaining the achievements until reaching the RMC standard.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIn this study, the recommended actions to sustain RMC include promoting women-centered care, improving healthcare provider personal attitudes, abiding on the profession, building community trust, ensuring a conducive environment in health facilities, and leadership should be actively involved and provide support.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Strengths and Limitations","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOne strength of this study is the utilization of the Appreciative Inquiry approach, which provided a positive way forward by shifting from problem-focused to solution-seeking perspectives. The recommendations yield from this study are applied to low resources health settings and envisage to improve RMC and working with the current available resources.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eHowever, a limitation is that the findings are solely based on the respective participants' views.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations. The study protocols were approved by the University of Rwanda Institutional Review Board (Approval Notice:\u0026nbsp;No 070/CMHS-IRB/2023, the National Health Research Committee (NHRC) of the Ministry of Health (MoH) of Rwanda (Reference: NHRC/2022/PROT/003), and the Human Ethical Research Committee (HREC) from Wits University (Approval Notice: No M220265). Permission was also obtained from the study sites. Informed consent was obtained from all participants involved in the study. None of the participants were minors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files]. \u0026nbsp; The datasets generated and analysed during the current study are available in the Supplementary Data1_ Excel output from Invivo 12 analysis of health care providers\u0026rsquo; interviews and focus groups repository\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: \u0026nbsp;This research was funded by CARTA and University of Rwanda (UR)/Swedish International Development Cooperation Agency (SIDA) program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAM\u003c/strong\u003e was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth \u0026amp; Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the Fellow.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlice Muhayimana: Conceptualization, Methodology, Data collection, Data transcribing, Formal analysis, Writing - Original draft preparation and editing.\u003c/p\u003e\n\u003cp\u003eIrene Josephine Kearns: Conceptualization, Supervision, Methodology, Formal Analysis, Writing - Original draft preparation, reviewing \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our gratitude to the healthcare providers who took part in this research. We also express our appreciation to the hospital managers at the research sites. Furthermore, our sincere thanks go to our collaborators, including University of Witwatersrand, CARTA and facilitators, as well as the UR/SIDA program, for their generous financial support for this endeavor, in addition to the collaboration with Rwanda Biomedical Center and Rwanda Ministry of Health.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBante, A., Teji, K., Seyoum, B., Mersha, A. 2020. Respectful maternity care and associated factors among women who delivered at Harar hospitals, eastern Ethiopia: a cross-sectional study. BMC Pregnancy and Childbirth, 20 (1), 86. \u003cu\u003ehttps://doi.org/10.1186/s12884-020-2757-x\u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eBohren, M.A., Tun\u0026ccedil;alp, \u0026Ouml;., Miller, S. 2020. Transforming intrapartum care: respectful maternity care. Best Practice \u0026amp; Research Clinical Obstetrics \u0026amp; Gynaecology, 67, 113\u0026ndash;126. 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International Journal of Pregnancy and Childbirth, 5 (1), 10\u0026ndash;17. DOI: \u003cu\u003e10.15406/ipcb.2019.05.00140\u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eKorstjens I, Moser A. Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing. European Journal of General Practice. 2018 Jan 1;24(1):120-4.\u003c/li\u003e\n\u003cli\u003eKujawski SA, Freedman LP, Ramsey K, \u003cem\u003eet al\u003c/em\u003e. Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga region, Tanzania: a comparative before-and-after study. \u003cem\u003ePLoS Med \u003c/em\u003e2017;14:e1002341.\u003c/li\u003e\n\u003cli\u003eLincoln, Y. S., \u0026amp; Guba, E. G.But is it rigorous? trustworthiness and authenticity in naturalistic evaluation. \u003cem\u003eNew Directions for Evaluation\u003c/em\u003e, \u003cem\u003e1986\u003c/em\u003e(30), 73\u0026ndash;84. https://doi.org/10.1002/ev.223\u003c/li\u003e\n\u003cli\u003eMaternal and Child Survival Program (MCSP) Rwanda Technical Brief:Maternal Health, 2017 accessed on https://pdf.usaid.gov/pdf_docs/PA00SVRQ.pdf\u003c/li\u003e\n\u003cli\u003eMdoe, P., Mills, T.A., Chasweka, R., Nsemwa, L., Petross, C., Laisser, R., Chimwaza, A., Lavender, T. 2021. Lay and healthcare providers\u0026rsquo; experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: an Appreciative Inquiry. BMJ Open, 11 (9), e046248. DOI: 10.1136/bmjopen-2020-046248\u003c/li\u003e\n\u003cli\u003eMore Happy Birthdays project, 2022 accessed on https://internationalmidwives.org/assets/files/project-files/2022/09/20220925-mhb-project-final-report.pdf\u003c/li\u003e\n\u003cli\u003eMuhayimana A, Kearns IJ, Gishoma D, Tengera O, Uhawenimana TC. Experiences and perceptions of respectful maternity care during childbirth in health facilities of Eastern province of Rwanda: An Appreciative Inquiry (unpublished)\u003c/li\u003e\n\u003cli\u003eMukamurigo J, Dencker A, Ntaganira J, Berg M. The meaning of a poor childbirth experience\u0026ndash;a qualitative phenomenological study with women in Rwanda. PloS one. 2017 Dec 8;12(12):e0189371.\u003c/li\u003e\n\u003cli\u003eNdirima, Z., Neuhann, F., \u0026amp; Beiersmann, C. (2018). Listening to their voices: understanding rural women\u0026rsquo;s perceptions of good delivery care at the Mibilizi District Hospital in Rwanda. \u003cem\u003eBMC women\u0026apos;s health\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e, 1-11.\u003c/li\u003e\n\u003cli\u003eNishimwe A, Conco DN, Nyssen M, Ibisomi L. Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda: a qualitative study. BMC nursing. 2022 Jan 4;21(1):9. \u003c/li\u003e\n\u003cli\u003ePolit D, Beck C. Essentials of nursing research: Appraising evidence for nursing practice. Lippincott Williams \u0026amp; Wilkins; 2020 Dec 30.\u003c/li\u003e\n\u003cli\u003eRominski, S. D., Lori, J., Nakua, E., Dzomeku, V., \u0026amp; Moyer, C. A. (2017). When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out: justification of disrespectful and abusive care during childbirth among midwifery students in Ghana. \u003cem\u003eHealth policy and planning\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(2), 215-224.\u003c/li\u003e\n\u003cli\u003eRosen HE, Lynam PF, Carr C, Reis V, Ricca J, Bazant ES, Bartlett LA, Quality of Maternal and Newborn Care Study Group of the Maternal and Child Health Integrated Program. Direct observation of respectful maternity care in five countries: a cross-sectional study of health facilities in East and Southern Africa. BMC pregnancy and childbirth. 2015 Dec;15:1-1.\u003c/li\u003e\n\u003cli\u003eShakibazadeh, E., Namadian, M., Bohren, M.A., Vogel, J.P., Rashidian, A., Nogueira Pileggi, V., Madeira, S., Leathersich, S., Tun\u0026ccedil;alp, Ӧ., Oladapo, O.T., Souza, J.P. 2018. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology, 125 (8), 932\u0026ndash;942. doi: \u003cu\u003e10.1111/1471-0528.15015. Epub 2017 Dec 8.\u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eStavros JM, Godwin LN, Cooperrider DL. Appreciative inquiry: Organization development and the strengths revolution. Practicing organization development: Leading transformation and change. 2015 Geneva, Switzerland. ISBN 978-92-4-155021-5\u003c/li\u003e\n\u003cli\u003eThe New Times, Rwanda.Accelerating progress in achieving respectful maternity care in Rwanda, 2023 https://www.newtimes.co.rw/article/12755/opinions/accelerating-progress-in-achieving-respectful-maternity-care-in-rwanda [accessed on 23 December 2023)\u003c/li\u003e\n\u003cli\u003eWarren CE, Ndwiga C, Sripad P, Medich M, Njeru A, Maranga A, Odhiambo G, Abuya T. Sowing the seeds of transformative practice to actualize women\u0026rsquo;s rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research. BMC women\u0026apos;s health. 2017 Dec;17(1):1-8.\u003c/li\u003e\n\u003cli\u003eWhite Ribbon Alliance. 2019. RMC charter: universal rights of mothers and newborns. https://whiteribbonalliance.org/wp-content/uploads/2022/05/WRA_RMC_Charter_FINAL.pdf\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. 2018. WHO recommendations: Intrapartum care for a positive childbirth experience. WHO, Afulani, P.A., Phillips, B., Aborigo, R.A., Moyer, C.A. 2019. Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India. The Lancet Global Health, 7 (1), e96-e109. https://doi.org/10.1016/S2214-109X(18)30403-0\u003c/li\u003e\n\u003cli\u003eWorld Health Organization; Quality of improvement of maternal and newborn care quality, World Health Organization, 2016\u003c/li\u003e\n\u003cli\u003eDhakal, P., Creedy, D.K., Gamble, J., Newnham, E., McInnes, R. 2022. Educational interventions to promote respectful maternity care: a mixed-methods systematic review. Nurse Education in Practice, 103317. DOI: 10.1016/j.nepr.2022.103317\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-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"positive childbirth, appreciative care, best practices, mother-friendly care, Rwanda","lastPublishedDoi":"10.21203/rs.3.rs-3824494/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3824494/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Childbirth demands respect, as emphasized by the World Health Organization in 2018 and the focus towards the need for positive, dignified delivery experiences, has become an integral aspect of Respectful Maternity Care (RMC). It is a known fact that RMC is pivotal for favorable birth outcomes and reduce mistreatment during childbirth. Absence of RMC violates women and newborns' rights, and the study aims to explore Health Care Providers' perspectives on sustaining RMC actions previously reported by mothers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e: This study was conducted in five hospitals in the Eastern province of Rwanda, involving 5 Focus Group Discussions (FGDs) with midwives and nurses. For interviews, we purposively selected 5-unit managers and 5 physicians. Additionally, 40 midwives and nurses were recruited for the FGDs. The research utilized the Dream phase of Appreciative Inquiry (AI) for interviews and Focus Groups. Data collection aimed to gain insights into Healthcare Providers' perceptions of how RMC is provided and how to establish and to sustain RMC in Rwandan health facilities. Nvivo 12 was employed for organizing codes and creating a codebook, and thematic analysis was applied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 4 themes emerged and their sub-themes.1) \u003cem\u003e\u003cstrong\u003eWomen centered care\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003e\u003cem\u003ewith\u003c/em\u003eCompassionate care, Privacy and confidentiality maintenance, Information provision and liberty in decision making, Effective communication, Family involvement\u003cstrong\u003e, \u003c/strong\u003eCleanness Equality care. 2)\u003cem\u003e\u003cstrong\u003eProfessionalism compliance\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003ewith Motivated staff, Teamwork, Continuous development,\u003cstrong\u003e \u003c/strong\u003eQuality work provision, Community trust. 3)\u003cstrong\u003e \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRMC encounters\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e 4) \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eRMC sustenance\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion and recommendations\u003c/strong\u003e: The continuous pursuit of high RMC standards in Rwanda involves improving childbirth experiences through utilizing existing resources, ongoing improvement, and sustaining achievements. Key recommended actions in this study for sustaining RMC encompass promoting women-centered care, enhancing healthcare provider attitudes, ensuring professionalism, building community trust, maintaining conducive health facility environments, and involving leadership\u003c/p\u003e","manuscriptTitle":"Healthcare Providers' Perspectives on Sustaining Respectful Maternity Care Appreciated by Mothers, in Five Hospitals of Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-08 09:50:53","doi":"10.21203/rs.3.rs-3824494/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-01-05T07:59:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-05T04:33:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-05T04:33:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2023-12-30T16:36:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dd47e24b-efac-4734-a72d-42c50dadafb1","owner":[],"postedDate":"January 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-15T05:31:33+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-08 09:50:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3824494","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3824494","identity":"rs-3824494","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}