A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care

Abstract

We have limited understanding of the organisational issues at the health facility-level that impact providers and care as it relates to mistreatment in childbirth, especially in low- and middle-income countries (LMICs). By extension, it is not clear what types of facility-level organisational changes or changes in working environments in LMICs could support and enable respectful maternity care (RMC). While there has been relatively more attention to health system pressures related to shortages of staff and other resources as key barriers, other organisational challenges may be less explored in the context of RMC. This scoping review aims to consolidate evidence to address these gaps. We searched literature published in English between 2000–2021 within Scopus, PubMed, Google Scholar and ScienceDirect databases. Study selection was two-fold. Maternal health articles articulating an organisational issue at the facility- level and impact on providers and/or care in an LMIC setting were included. We also searched for literature on interventions but due to the limited number of related intervention studies in maternity care specifically, we expanded intervention study criteria to include all medical disciplines. Organisational issues captured from the non-intervention, maternal health studies, and solutions offered by intervention studies across disciplines were organised thematically and to establish linkages between problems and solutions. Of 5677 hits, 54 articles were included: 41 non-intervention maternal healthcare studies and 13 intervention studies across all medical disciplines. Key organisational challenges relate to high workload, unbalanced division of work, lack of professional autonomy, low pay, inadequate training, poor feedback and supervision, and workplace violence, and these were differentially influenced by resource shortages. Interventions that respond to these challenges focus on leadership, supportive supervision, peer support, mitigating workplace violence, and planning for shortages. While many of these issues were worsened by resource shortages, medical and professional hierarchies also strongly underpinned a number of organisational problems. Frontline providers, particularly midwives and nurses, suffer disproportionately and need greater attention. Transforming institutional leadership and approaches to supervision may be particularly useful to tackle existing power hierarchies that could in turn support a culture of respectful care.

Global health systems strengthening: FIGO's strategic view on reducing maternal and newborn mortality worldwide

“…As training is linked to career advancement, a lack of training opportunities for practicing healthcare personnel contributed to poor motivation and work performance. 6 In addition, promoting respectful care is increasingly recognized as a critical element in improving the utilization and quality of maternity care for a positive childbirth experience. 20 In Rwanda, a strategic project aimed at increasing the number of trained health providers, particularly in rural service areas, included comprehensive interventions, such as professional development, supervision, and competitive compensation packages.…”

“…A recent scoping review emphasized that enhancing the skills of providers and managers in LMICs should be synergized with other strategies, such as supervision and collaborative problem‐solving, to amplify their effectiveness. As training is linked to career advancement, a lack of training opportunities for practicing healthcare personnel contributed to poor motivation and work performance 6 . In addition, promoting respectful care is increasingly recognized as a critical element in improving the utilization and quality of maternity care for a positive childbirth experience 20 …”

“…There is an acknowledged perspective of the critical intersection of maternal and fetal well-being, emphasizing the need for an integrated health system that caters to mothers and children across the pregnancy, birth, postpartum, and perinatal continuum. 6 This approach aims to avoid dichotomies between mothers and newborns regarding interventions, places of service delivery, or health issues. Evidence exists that maternal and perinatal mortality reduction efforts fail because of fragmented systems and a scarcity of resources that are disproportionately allocated toward emergency medical responses, overshadowing preventive care and the broader social determinants of health.…”

“…Inseparable linkages between the health and well‐being of the mother, the fetus, and the future newborn are well recognized. There is an acknowledged perspective of the critical intersection of maternal and fetal well‐being, emphasizing the need for an integrated health system that caters to mothers and children across the pregnancy, birth, postpartum, and perinatal continuum 6 . This approach aims to avoid dichotomies between mothers and newborns regarding interventions, places of service delivery, or health issues.…”

Trends and motivations for freebirth: A scoping review

“…3 The term is mainly used in high-income countries (HICs), where maternity care services are generally available and accessible. In contrast, women in low-and middle-income countries (LMICs) are only recently shifting to birthing in facilities 4 because such services were previously less accessible. Thus, these women often give birth alone without professional assistance, and doing so is regarded as the norm in LMICs.…”