Strategies for facilitating and sustaining respectful maternity care in Rwanda: an expert review

¹Department of Nursing Education, School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa, ²School of Nursing and Midwifery, University of Rwanda, Kigali, Rwanda, ³University of Utah, College of Nursing, Utah, Salt Lake City, USA, ⁴Duke University, School of Nursing, North Caroline, Durham, USA

^&Corresponding author
Irene Josephine Kearns, Department of Nursing Education, School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa

Introduction    

Childbirth is a profound human experience that deserves the utmost respect. In 2018, the World Health Organization (WHO) highlighted the importance of ensuring a positive and dignified child delivery experience for every woman [1]. Providing Respectful Maternity Care (RMC) plays a significant role in mother´s satisfaction and enhancing the quality and utilization of maternity services [2-5]. The absence of RMC constitutes a violation of the rights of women [6-10]. Facilitating and sustaining RMC in health facilities is particularly effective in reducing intrapartum mistreatment, enhancing positive birth outcomes, and fostering positive childbirth experiences. Over the past three decades, Rwanda has made substantial strides in rebuilding its economic and social infrastructure post-1994 genocide against the Tutsis. These efforts have propelled Rwanda to become one of Africa's most successful nations, credited to robust government policies [11,12]. Rwanda prioritizes women's rights, evidenced by significant progress in gender equality in political representation, surpassing all nations in the percentage of women in parliamentary positions [13], demonstrating a strong commitment to women's empowerment across society. Respect holds a foundational role in Rwandan culture and leadership, shaping traditional social interactions [14]. Incorporating this culture of respect into the childbirth process is vital for advancing women's and newborns' rights and promoting the overall well-being of the population. Rwanda has a political commitment to improving women's and newborns' health, as evidenced by the implementation of various programs and initiatives for maternal and child health in Rwanda [15-19]. This has led to significant progress, achieving Millennium Development Goals (MDGs) 4 and 5, notably reducing neonatal and maternal mortality rates [20], and Rwanda is committed to progress and achieving the Sustainable Development Goals (SDGs) targets by 2030 [21].

Previous studies in Rwanda have not documented strategies to facilitate RMC during labour and childbirth [22-24]. Our study was designed to develop and validate strategies for facilitating and sustaining respectful care during labour in Rwanda's health facilities. While Rwanda currently lacks a standalone policy specifically for addressing RMC, certain RMC components have been incorporated into the Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) policy [25]. Despite this, some activities to improve RMC have been conducted. Initial interest in RMC has been integrated into basic emergency obstetric and newborn care. National consultation meetings have been held with RMC stakeholders in Rwanda to address disrespect and abuse [26]. In some health facilities, healthcare providers have received RMC training and mentorship in collaboration with the Rwanda association of midwives and the Ministry of Health through initiatives like the maternal and child survival program [27] and the more happy birthdays project [28]. This study aimed to develop and validate the strategies for facilitating and sustaining RMC in Rwanda's health facilities. Those strategies are critical for promoting a positive childbirth experience, reducing mistreatment, and improving the quality of maternity and health outcomes for mothers and newborns. In addition, this study filled the gap in comprehensive documentation and strategies for RMC in Rwanda. Through an expert review approach, the study created a proposed framework for implementing RMC at the policy, health facility, and community levels.

Methods     

Study design and setting: we used a quantitative descriptive by utilizing an expert review approach and the strategic formulation process to develop the detailed proposed plan. This article forms part of a doctoral project phase aimed at developing and validating strategies to facilitate and promote RMC in Rwanda. The preceding phases involved mothers who gave birth and healthcare providers working in maternity services. In previous phases, we described mothers´ experiences and the experiences of healthcare providers. Appreciative Inquiry (AI) was used to guide our work. Appreciative inquiry is commonly known as an "asset-based" or "strengths-based" approach for driving change within systems, highlighting the generation of positive concepts and perspectives [29]. Appreciative Inquiry serves as a potent strategy for instigating positive change across individual, team, organizational, and societal realms, facilitating the refinement of a shared vision for the future through strategic innovation [26,29-31]. Appreciative Inquiry embraces a 5D cycle of the definition, discovery, dream, design, and destiny phases [29,30].

In this study, we used "design" to integrate the findings and validate and develop the strategies. The design stage of AI generates options for implementation and co-construct plans by focusing on "what should be the ideal?" [29,30]. The design phase articulates the strategic focus, including a vision of sustainability and a compelling statement of strategic intent [29,30]. In this study, through the development and validation of RMC strategies, participants proposed strategies, action plans, and procedures to improve and facilitate RMC in Rwanda. Our strategies were developed based on integrated findings from previous study phases involving mothers who had given birth and healthcare providers working in maternity services across five public hospitals in the Eastern Province of Rwanda. These hospitals included three district hospitals, one provincial hospital, and one referral hospital. The validation process was conducted individually and online via email communication.

Study population: we purposefully identified and contacted ten national and international experts and stakeholders with the requisite expertise and skills in the RMC field for the validation process. Participants included individuals with extensive experience in RMC, such as leaders of maternity services, university lecturers, researchers, policymakers, and representatives of community maternity care and research. We excluded participants who were involved in previous phases of this study. Among the international experts were two faculty members from the USA specializing in maternal health, who typically supervised doctoral research in RMC; a leader in clinical services at a mother and child hospital in South Africa; and a researcher in RMC from Nigeria. The national experts included the president of the Rwanda Association of Midwives, the Director of Maternal Child and community health from the Rwanda biomedical center in the Ministry of Health, two faculty members from the midwifery department of the University of Rwanda, a director of nursing from a hospital at the study site, and a community representative in various research projects in Rwanda. Each participant took part individually.

Data collection: based on the integration of previous findings from the earlier phases of our work [32-35], we developed five strategies and action items to be used as a tool to operationalize and validate the strategies. Expert review entails seeking guidance from those with extensive expertise, mentorship, teaching, or research experience [36-38]. Expert review approaches have been utilized to evaluate the content in other studies [37,38]. In this study, we explained the aim of the expert review and identified the specific components the experts needed to assess. We defined the criteria necessary to assess the strategies and encouraged them to document their observations by offering specific recommendations or actionable steps. The RMC experts and stakeholders received a Personal Information Sheet (PIS), a socio-demographic data sheet, and a document (questionnaire) containing the strategies to validate. The questionnaire we used in the expert review utilized a four-point Likert scale ranging from 1 to 4, where 1 represented the lowest grade and 4 the highest grade for each item. The experts evaluated and rated each strategy and action plan based on the relevance, feasibility, acceptability, and context of each criterion. A free space for explanatory remarks was also provided for the participants to offer additional suggestions and actionable insights. Based on their expertise (see the validation tool). After the validation process, we prioritized the strategies based on their highest-ranking percentage scores. Through the strategic formulation process, we developed a detailed plan of action and goals and determined the proper blueprint to achieve these goals by proposing practical implementation. The validated strategies and action plans were prioritized, specifying objectives, levels of implementation (policy, hospital leadership management, healthcare providers, service users, community), activities/tasks, responsible persons, timelines, and follow-up mechanisms.

Definitions

A strategy: this refers to a structured, comprehensive plan, a blueprint, or a set of actions devised to attain a particular objective successfully [16]. A strategy is an approach or series of steps designed to accomplish a specific goal or desired outcome [39,40]. Strategy formulation is establishing goals and determining the proper plan of action to achieve those goals [39,41]. Strategy formulation involves setting priorities [42].

Relevance: refers to a scientific or societal benefit of a topic in the context of respectful maternity care.

Feasibility: refers to technical and logistical considerations to uptake the proposed strategies and action plan of respectful maternity care.

Acceptability: focus on how well the strategies and action plan will be received by mothers, the community, health care providers, hospital management, and the health system, considering what was appreciated by service users (mothers) and service givers caring for women during labour and childbirth based on culture, ethics, opportunities, and collaborations available in Rwanda.

Context: includes various factors; the maternity setting, historical background, cultural influences, and relationships between different elements.

Statistical analysis: due to the limited number of participants, we conducted only descriptive statistics. After receiving feedback from RMC experts and stakeholders, we summed the frequency of each criterion and calculated the corresponding percentages. We then averaged the percentages of the four criteria to determine the rate for each validated strategy. Finally, we computed the overall average percentage for all five strategies and ranked them from highest to lowest based on these results (Table 2).

Ethical considerations: all methods were carried out by relevant guidelines and regulations. The study protocols were approved by the University of Rwanda Institutional Review Board (Approval Notice: No 070/CMHS-IRB/2023) and the Human Ethical Research Committee (HREC) from Wits University (Approval Notice: No M220265). Informed consent was obtained from all participants involved in the study. None of the participants were minors.

Results     

Participants

General characteristics of the study population: of the ten participants involved in validating the RMC strategies, 40% were international. The majority (60%) have a background education in maternal health (Table 1).

Main results: the scores were derived from the summation of the frequency of the four criterion scores, translated into percentages. Consequently, the strategies' scores ranged from 86% to 91%. The two highest-scoring strategies, each with 91%, are "Promoting women-centered care and positive childbirth experiences" and "Preserving and upholding community trust in maternity services." The strategy with the lowest score, at 86%, is "maintaining and promoting an adequate (safe) environment around the childbirth facility" (Table 2). "Promoting women-centered care and positive childbirth experiences" was deemed the most relevant strategy, with a relevance score of 100%. Overall, the relevance scores across the strategies ranged from 85% to 100%. The feasibility scores ranged from 80% to 88%. The strategy "to preserve and uphold community trust towards maternity services" was the most acceptable, scoring 98%, and also the most context-based, scoring 95%. The acceptability of the strategies ranged from 85% to 98%, while the context-based scores varied between 80% and 95% (Table 2).

Proposed logical framework: we propose the following logical framework for implementing the developed strategies in Rwandan health facilities (Figure 1). A logframe, also known as a logical framework, is a planning tool comprising a matrix that comprehensively views a project's objectives, activities, and expected outcomes [43,44]. It precisely defines project elements and activities while establishing connections between them [44,45] (Figure 1). The logical framework illustrates the association between our developed RMC strategies and the anticipated outcomes (Figure 1). We created a general logical framework without details that encompasses the project's long-term objective, ensuring that every woman has a positive childbirth experience. The outcomes are achievements expected over time, including increased mothers' satisfaction, improved maternal and neonatal outcomes, enhanced positive reputation and expectations, and increased maternity services utilization. Outputs are immediate results obtained soon after completing the project or specific activities [44,45]. These are the key objectives outlined in the project's terms of reference. Outputs represent the tangible results for which the project team is directly responsible and for which resources are allocated [46].

Discussion     

This study aimed to develop and validate strategies for sustaining respectful maternity care in Rwandan health facilities. Our research identified five main strategies, with the two highest-scoring strategies (91%) are promoting women-centered care and positive childbirth experiences and preserving and upholding community trust in maternity services.

Multiple strategies: one of the prominent findings from this study is that sustaining and promoting Respectful Maternity Care requires the implementation of multiple strategies. Downe reported that implementing multi-component RMC policies tends to decrease disrespect towards women [47]. The literature argues that delivering respectful and high-quality maternity care to women necessitates comprehensive and multifaceted initiatives and should incorporate structural changes [2,47-51]. A worldwide meta-synthesis on midwives' and women's experiences with RMC revealed that multiple strategies can increase positive childbirth [52]. Convincingly, interventions with multiple components addressed at different levels are more likely to yield meaningful change in RMC than relying solely on a single focus [2,52,53]. Our proposed action plan target policymakers, health leaders, facility managers, communities, and individuals. This approach aligns with findings from other studies, emphasizing the necessity for customized RMC interventions at various system levels [51-54].

Women-centred care: during the validation, all participants responded that the promotion of women-centered care is the most relevant at 100% (Table 2). These findings are consistent with a study conducted in Iran, which suggested advancing RMC by implementing women-centered, evidence-based, and humanized care and providing supportive care through friendly interactions [55]. Our study advocates for a shift towards building on positive experiences. Notably, women's positive experiences during labor and childbirth include emotional support, positive attitudes from providers, and effective communication [9,56]. Other studies reported that positive interpersonal relationship factors; effective communication, timeliness, and confidentiality, were consistently linked to high satisfaction levels [56,57].

Conducive environment: apart from positive interpersonal interactions between service providers and recipients, our findings highlight that a conducive environment contributes to positive childbirth experiences. The conducive environment includes hospital hygiene, availability of materials and equipment, non-sharing of beds, and appropriate payment for services received. The findings from other studies argue that measures to ensure RMC are influenced by interpersonal interactions and facility characteristics like a supportive environment [8,58,59]. Bohren emphasized that to provide respectful care, health facilities, and systems should be organized and ensure sufficient infrastructure and organization within the maternity ward [60].

Training and follow-up: our findings revealed that providing RMC training to both clinicians and non-clinician staff in health settings is crucial. An interventional study conducted in Iran, which included training for both clinicians and non-clinicians to promote RMC, demonstrated a significant decrease in anxiety and depression in women before and after the intervention. [55]. The review of RMC interventions in Africa conducted by Diamond-Smith showed that RMC training was the most useful action [53]. A study conducted in Afghanistan recommended increasing awareness among women and healthcare providers about women's rights to RMC, offering training on this topic, and monitoring care [61]. Achieving lasting behaviour change in RMC necessitated continuous support [53].

Motivating healthcare providers: our findings revealed that motivating healthcare providers can facilitate RMC provision. These suggested practices in our study are similar to those found in the systematic review: presenting trophies or showcasing photographs of staff members who performed well, and may foster intrinsic motivation among staff to adhere to RMC principles [48,54]. The study recommended that hospital management should consider the factors that motivate midwives [62]. In healthcare settings, various strategies have been implemented to inspire and engage staff, like non-monetary rewards providing snacks during working hours, to acknowledge and appreciate their contributions to RMC [48,54].

Context: our study produced strategies from what was appreciated by service users and providers, marked as feasible, and contextually accepted. Respectful maternity care is multidimensional and dynamic [7,8], and sustainable solutions for maintaining respectful actions must be identified within the local context [8-10]. Exploring feasible and appreciated methods in low-resource settings is crucial. Utilizing available means in settings where infrastructure, workforce, and equipment are still limited can yield better results with positive reinforcement instead of focusing on challenges and blaming providers [63].

Next steps and proposals: we plan to communicate the findings to policymakers in the Ministry of Health to encourage policy development and implementation in Rwanda. We target to uphold the universal rights of women and newborns, following the guidelines established by the white ribbon alliance [54] and WHO components of a positive childbirth experience, which include communication with women and their families, equitable care with respect, and preservation of dignity, culturally sensitive care, emotional support, privacy and confidentiality, and respecting women's choices around childbirth [64] (Figure 1). We will train healthcare providers and non-clinical staff across various health settings to implement the developed strategies for RMC in Rwanda. Expected outcomes include improved staff training, enhanced client-provider relationships, better hospital hygiene, adequate equipment, private rooms, and promoted birth companionship. Evaluations through policy development and community awareness campaigns will measure the strategies' effectiveness.

Achieving RMC requires collaboration among stakeholders, health administrators, political actors, media, human rights activists, civil societies, NGOs, healthcare professionals, leaders, and the community [48,53]. Respectful maternity care should be incorporated into pre-service and in-service education using a low-dose, high-frequency model. Regular RMC training, mentoring, and counseling for healthcare providers are essential. An RMC oversight individual and committee at each hospital, provider exchange programs, and a comprehensive monitoring and evaluation plan are recommended. Educational initiatives on RMC should be integrated into antenatal clinics, and community awareness efforts should promote RMC widely. Future studies, including intervention trials, are recommended to test and compare RMC practices in private and public hospitals and assess RMC across the life course continuum. The strength of this study is the use of Appreciative Inquiry, which led to identifying strategies and actions that resonate with Rwanda's cultural and contextual realities. The limitation of this study was the use of one province of Rwanda. In addition, transitioning to a strength-based approach requires persistence, practice, and patience. Appreciative Inquiry may not be suitable for some circumstances, especially when immediate action is needed.

Conclusion     

The findings of this study brought significant policy implications for promoting Respectful Maternity Care (RMC) in Rwanda. There should be a strong focus on women's needs and preferences, along with training and motivating Health Care Providers (HCPs) in order to advance RMC. Creating a conducive environment around labour and childbirth and engaging the community and policymakers is essential. The Ministry of Health of Rwanda should establish standard RMC practices in all health facilities. Building upon positive experiences and encouraging optimism are crucial to promote sustainable change for RMC provision in Rwanda. Sustainability requires integrating RMC into the broader health system and collaborating with relevant stakeholders; implementers, advocates, policymakers, researchers, and donors to influence the adoption of RMC. Sustaining and promoting RMC through a strength-based approach is an ongoing journey requiring consistent practice and perseverance.

Competing interests     

The authors declare no competing interests.

Funding     

Alice Muhayimana was supported by the Consortium for Advanced Research Training in Africa (CARTA). Consortium for Advanced Research Training in Africa 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     

Conception and study design: Alice Muhayimana and Irene Josephine Kearns. Data collection: Alice Muhayimana and Irene Josephine Kearns. Data analysis and interpretation: Alice Muhayimana and Irene Josephine Kearns. Manuscript drafting: Alice Muhayimana and Jane Blood-Siegfried. Manuscript revision: Alice Muhayimana, Irene Josephine Kearns and Katie Ward. All authors approved the final version of the manuscript.

Acknowledgments     

A vote of thanks goes to the participants who participated in this study; the international/national experts and stakeholders in respectful maternal and newborn care. We would also like to thank our study partners, CARTA, facilitators and the UR/SIDA program for providing funds for this work and Rwanda Ministry of Health.

Tables and figure     

Table 1: socio-demographic characteristics of participants in validation n=10

Table 2: summarized validation findings

Figure 1 : proposed logical framework for RMC strategies implementation in Rwanda

References