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Results

The purpose

of this review of literature is to examine various methods of provider

educational training regarding respectful maternity care(RMC) and associated impact on patient

care. The studies found were performed in various parts of the world with one each in Gha

na,

England

, Tanzania

, and two each in Ethiopia and India.

All seven studies

specified the

number of

providers

as participants

and five also

included

patients

The studies also

included the type of

provider (i.e., anesthesiology, midwifery, obstetrics)

, ex

cept for one.

The studies reviewed

focused on provider

specific interventions for improving or initiating RMC.

Outcom

es were measured in various ways across the studies

Measurements

used

included analyzed participant notes, quizzes,

Self

Childbirth

Chec

klist

SCC

)

(

erson

entered

aternity

care s

cale

overall assessment of

hospital practices and ecosystem, and survey

Interviews and group discussions werealso commonly used in combination with various studies.

The

SCC

, a validated tool, was only used to measure privacy during birth and if a companion

was offered.

The

person

centered maternity care scale

is a validated tool with 30 items and three

subscales for dignity and respect, communication and autonomy, and suppor

tive care.

Only 24

items were used in theassociated study.

Table 3 demonstrates data extraction and the main

findings of each study.

Interventions

were classified by educational styles

(

visual, auditory, kinesthetic,

reading/writing), length (short, inter

mediate, long)

and if

RMC

was integrated into a study, or

studied independently

Education

Styles

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Throughout the studies, different styles of education were classified to allow for

comparison. Styles included

reading and writing, kinesthetic (actively doing or practicing the

intervention), auditory

(

listening, discussing),

and visual (diagrams, pictures, videos).

Specifically, interventions providing examples of disrespectful care and using transformative

lear

ning to create realistic clinical situations proved to be impactful. Cooperative learning and

multidimensional learning were shown to be effective in creating change (Afulani, 2018;

Swordy, 2020;

Taneja, 2021;

Wilson

Mitchell, 2018).

One study incorporated

all aspects of

learning and was able to show change in all domains of RMC, although not statistically

significant (p=0.08; Asefa, 2020).

Reading and Writing

our

studies used reading and writing as learning styles.

Methods included readings,

participant

reflection, writing notes about videos, and reading posted job aides.

Asefa (2020)

specifically created a manual about RMC as a long

term resource.

Sharma (202

)

and Taneja

(2021)

utilized

posted informational sheets and job aids

throughout the unit.

Instead of reading

about information, Swordy (2020), used writing as a method of reflection and expression during

a video clip intervention.

Kinesthetic

Five studies included kinesthetics

in various forms to simulate RMC

Two studies

utilized skills sess

ions

(

Afulani, 2018; Mengistu, 2021) and another two, role play

Asefa

2020

;

Wilson

Mitchell, 2018)

. Sharma (2021)

was structured as

plan

study

act (PDSA)

cycles

performed on a labor unit, so participants were constantly practicing and improving RMC sk

ills.

Afulani (2018) focused on

simulation of stressful maternity care situations

and found them

effective in creating positive change to RMC over a 6

month period (p<0.001).

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Auditory

All seven studies used a form of auditory learning. F

ive

used a style

of discussion during

or after the intervention

(

Asefa, 2020; Mengistu, 2021; Sharma, 2021; Swordy; 2020; Wilson

Mitchell, 2018)

Afulani (2018) included a learning module presentation. Throughout one study,

monthly mentorship meetings were established to d

iscuss,

assess,

and evaluate interventions

(

Taneja,

2021).

Through PDSA cycles previously discussed, ongoing conversation and

sensitization of RMC created significant change in RMC with 93% of providers obtaining

consent before examination compared with 47

% prior (Sharma, 2021).

One study focused on the

intellectual partnership model of encouraging education to be dynamic with the teacher and

learner to promote more discussion, cooperative learning, and empowerment. Participants were

able to increase quiz r

esults by 20% post

intervention (Wilson

Mitchell, 2018).

Visual

Five studies included visual learning with

four

of these showing a type of video

(

Asefa,

; Mengistu, 2021; Swordy, 2020; Wilson

2020

Mitchell, 2018).

Videos were the focus of two

studies and specifically focused on providing realistic scenarios of disrespectful care

(

p<0.001 in

one district)

and reported patient experiences, respectively. Both studies had positive feedback

regarding the emotional aspects of such videos and subseque

nt push for change to more

respectful care felt from participants (Mengistu, 2021; Swordy, 2020).

Another intervention used

were anatomically marked scrubs that were worn by models

(

Afulani,

2018).

Length

of Training

Length of educational training was fou

nd to have an impact on data collection and long

term sustainability of RMC. Short

term trainings were effective for situational awareness of

RMC. Longer

term trainings were able to evaluate impact of RMC

with patients and providers.

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With education, impact

is often not immediately found, and sustainability is a valuable

component.

Brief

Amongst the studies,

only covered short

term outcomes and were brief in length.

Swordy (2019) and Wilson

Mitchell (2018)

consisted of

one

and

two

day training workshops

respectively. These studies did not evaluate long

term impacts of RMC and focused more on

increasing

knowledge rather than practice change

. Qualitatively, they did get positive feedback

from participants regarding increased empowerment and empathy.

Intermediate

hree

studies were of intermediate length of 8 weeks

, 2 months, and

months,

respectively (Sharma, 2021;

Asefa, 2020;

Afulani, 201

8).

These studies were able to provide an

opportunity for repetition at some point in the study either through a refresher, focus group

discussion, or continued PDSA cycles.

Extended

The remaining two studies were over a longer period of 27 months and 24

months,

respectively (Mengistu, 2021; Taneja, 2021).

Repetition was also used in the form of PDSA

cycles, coaching visits,

and mentorship opportunities

. Mengistu (2021) found significant long

term change in two of the three districts (p<0.001, p=0.002). Ta

neja (2021) was able to integrate

RMC into

a long

term QI project with shown improved patient outcomes which will next be

discussed.

Integration vs Independence

RMC is not a singular intervention to care that can be introduced without discussion of

other aspects of labor and birth.

Four studies studied RMC on an independent level. These

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studies lacked long

term results and consistently cited improvements with prov

iders

understanding RMC on an emotional and empathetic level. While there were improvements in

knowledge of RMC and recognition of disrespectful care, long

term retention was unknown

(

Asefa, 2020; Sharma, 2021; Swordy, 2020; Wilson

Mitchell, 2018).

Three

studies examined RMC in connection with another aspect of maternity care.

Mengistu (2021) and Taneja (2021) integrated RMC into quality improvement projects

addressing other aspects of care. Afulani (2018)

used high

anxiety and stressful obstetric

situati

ons to make training more realistic for participants. This included an emotional

aspect but

was also shown to be more effective for retention of RMC.

Although, education regarding what RMC is and increased awareness of abuse and

disrespect are

valuable components to improving patient outcomes, long

term change requires

more. Integrated trainings with other aspects of maternal health allow learning to be more

realistic and therefore sustainable.

Discussion

Overall Findings

This systematic review

found

educational interventions with providers

about

RMC w

ere

impactful and effective in increasing respect and compassion. Providers reported increased

personal awareness

, knowledge regarding RMC

and

improved relationships with patients.

For

training to

be most effective, it should include various types of learning and specifically some

level of kinesthetic learning where participants can practice providing RMC. Education should

occur over

time

and include refreshers or mentorship opportunities to reinfor

ce concepts. RMC

should also be discussed in context with other aspects of maternity care since it is not a specific

intervention, but an overall practice change present in all aspects of care.

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Limitations

There were several limitations in this review.

All seven studies used convenience

sampling and relied on provider willingness to participate in educational intervention.

None

the studies

had randomization or

control group for ethical reasons.

Most of the studies did not

have a robust statistical a

nalysis, so it was unknown if results with positive outcomes were

statistically significant (Taneja, 2021; Wilson

Mitchel, 2018

;

Sharma, 2021).

Only one study had

blinding with

the intervention done (

Swordy, 2020

)

. Most studies were not largely impacted by

lack of blinding, but

Afulani

had non

(2018)

blinded,

person interviews

, that

could have been

biased.

There were only

two studies

with

a large sample size (Mengistu, 2021; Taneja, 2021)

Taneja (2021) had different baseline and endline assessments and

Afulani (2018) had different

baseline and endline samples.

As discussed earlier, three studies had a s

hort implementation

period

(

sefa,

2020

;

Swordy,

2020

;

Wilson

Mitchell

, 2018).

Only two studies used a replicable

and validated tool (Afulani, 2018; Mengi

stu, 2021).

Tools used were the person

centered

maternity care scale and

SCC

More research is needed to evaluate which is of more use with

RMC evaluation. Since the most long

term data was only over two

years,

it is also difficult to

determine RMC’s true

impact on maternal morbidity and mortality.

Practice Recommendation

This review suggests that RMC education increases provider knowledge, awareness,

compassion

and communication. It is unclear if RMC has an impact on patient

outcomes but

results thus far are supportive of future successes. Education should be integrated

with other

maternal health topics

and

done

by using various methods of learning

to increase

the likelihood

of retention

It is best to assess future success

interventions over a longer

period

with

intermediate refreshers on

learned

information

provided

. It is unclear which validated scale

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should be used

assess overall need of RMC, but it is

recommended to use one.

Summary

Disrespectful care

s clearly contributing to maternal morbidity and mortality on a global

level. Research is still new on educational interventions and best practice for incorporation

unknown

RMC cannot be learned qu

ickly or casually. It requires effort from the educator and

learner

to make lasting and sustainable change

garding the

culture of maternity care globally.

Lower resource countries are at a disadvantage to having multi

aceted education

due to lack of

avai

lable resources

. Efforts should be made on a global level to improve respect given to birthing

persons.

To start, providers need to be personally aware of the quality of care they give and the

impact it has on patient outcomes.

More research will be needed

discussing best practice

for

RMC

provider

education in all settings and areas of the world.

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References

Afulani, P. A., Aborigo, R. A., Walker, D., Moyer, C. A., Cohen, S., & Williams, J. (2018). Can

an integrated obstetric emergency simulation training improve maternity care? Results

from a pilot study in Ghana.

Birth

, 523

532

. https://doi.org/10.1111/b

irt.12418

Asefa, A., Morgan, A.,

Bohren, M.

& Kermode, M. (2020).

Lessons learned through respectful

maternity care training and its implementation in Ethiopia: An interventional mixed

methods study

Reproductive Health

(

103

)

https://doi.org/10.1186/s

12978

020

00953

Mengistu, B., Alemu, H., Kassa, M., Zelalem, M., Abate, M., Bitewulign, B., Mathewos, K.,

Njoku, K., Prose, N. S., & Maggie, H. (2021). An innovative intervention to improve

respectful maternity carein three Districts in Ethiopia.

BMC P

regnancy and Childbirth

(541)

. https://doi.org/10.1186/s

12884

021

03934

Sharma, B., Sikka, P., Arora, A., Assi, G. S., Suri, V. (2021). A quality improvement study on

improving communication between health

care provider and laboring woman: A step

toward respectful maternity care.

Indian Journal of Community Medicine

(3)

527.

Swordy, A., Noble, L. M., Bourne, T., Van Lessen, L., & Lokugamage, A. U. (2020). Footprints

of birth: An innovative educational intervention foregrounding women’s voices to

improve empathy and reflective practice in maternity care.

JCEHP

(3)

tps://

doi.org/

10.1097/CEH.0000000000000302

Taneja, G., Sarin, E., Bajpayee, D., Chaudhuri, S., Verma, G., Parashar, R., Chaudhry, N.,

Swarup Mohanty, J., Bisht, N., Gupta, A., Singh Tomar, S., Patel, R., Sridhar, V. S.,

Joshi, A., Rathi, C., Baswal, D., Gu

pta, S., & Gera, R. (2021). Care around birth

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approach: A training, mentoring, and quality improvement model to optimize intrapartum

and immediate postpartum quality of care in India.

Global Health: Science and Practice

(3)

. https://doi.org/10.9745/GHSP

00368

Wilson

Mitchell, K., Robinson, J., & Sharpe, M. (2018). Teaching respectful maternity care

using an intellectual partnership model in Tanzania.

Midwifery

, 27

https://doi.org/10.1016/j.midw.2018.01.019

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