Person-centred maternity care during childbirth: a systematic review in low and middle-income countries
In low- and middle-income countries (LMICs), institutional births have risen over the past two decades. However, evidence indicates that institutional births alone do not reduce maternal and newborn mortality without providing quality intrapartum care. Among different barriers to providing quality intrapartum care are non-compassionate and abusive care, which could lead to reduced rapport between women and healthcare providers and influence women’s future healthcare seeking. Evidence demonstrates that there is room for significant variation in assessing disrespectful and abusive care, and the findings are inconsistent. However, to examine the level of PCMC during childbirth without methodological variations, including different operational definitions, methodologies for generating summary measures, and variations of eligibility criteria like disrespectful and abusive care. To the best of our knowledge, no systematic review has been conducted to comprehensively assess the PCMC level in LMICs. Understanding the level of PCMC and its determinants could provide evidence to address this gap.   We systematically reviewed all published articles addressing the level of PCMC during childbirth and found 11 studies and 12 articles comprising 8341 women in six LMICs. PCMC levels during childbirth were shown to be higher in women who were wealthier and more educated, had better ANC experiences, and had received both ANC and birthing care by the same healthcare providers (Midwife-led care).   This finding demonstrates that low levels of PCMC occurred in the subdomain of communication and autonomy. Contextualised multifaceted interventions are needed to enhance the communication and autonomy subdomain during birth to improve PCMC.   Person-Centred Maternity Care (PCMC) is essential for improving intrapartum and immediate postnatal care quality and could lead to increased institutional birth and lower maternal and neonatal mortality in low- and middle-income countries (LMICs) . Despite international efforts to minimise maternal and newborn mortality in LMICs , many of these countries continue to have high mortality rates, with three-quarters of maternal deaths occurring in the postpartum period . While increasing facility births has been considered a potential strategy for lowering maternal and neonatal mortality rates, it is also essential to focus on enhancing the quality of intrapartum care. This notion is supported by studies from India and the Dominican Republic revealed that maternal and newborn mortality rates did not show significant decreases despite the increased rates of facility births . PCMC refers to compassionate care responsive to each woman’s and her family’s preferences, needs, and values during childbirth . PCMC includes responsive and respectful maternity care and treating patients with respect and dignity, good communication with patients in all health-related decisions and maintaining continuity of care . PCMC has subdomains such as dignity and respect, autonomy, privacy and confidentiality, communication, social support, supportive care, predictability and transparency of payments, trust, stigma and discrimination, a healthy facility environment . PCMC can help with the provision of care in a timely, better provider-patient communication, increased treatment adherence, and better maternal and neonatal birth outcomes . In LMICs, PCMC could be influenced by various factors, including the type of health facility, women’s wealth and educational status, mode of birth, obstetric complications, and burnout among healthcare providers due to issues such as non-payment of salaries, workforce shortages, and equipment/supply deficits during childbirth. These factors have substantial contribution to the occurrence of disrespectful, abusive, abandoning, and neglectful care, which, in turn, may lead to poor PCMC . Additionally, the increasing medicalisation of the childbirth process without involving women in the process, which tends to compromise a woman’s capacity to give birth and negatively impact her childbirth experience and subsequent health-seeking behaviour, contributing to poor PCMC . Thus, poor quality of PCMC, directly and indirectly, contributes to high maternal and neonatal deaths . Evidence demonstrates that inconsistencies arise in the findings regarding disrespectful and abusive during births, resulting from differences in operational definitions, methodologies for generating summary measures, and eligibility criteria. This is exemplified by significant variations in reported findings across different countries: the lowest non-dignified care such as shouted at, insulted, and threatened women during and after labour was reported in Malawi at 1.91% , overall, the highest level of disrespectful and abusive care was reported in Nigeria at 98.0% , and 98.9% in Ethiopia . Unlike these wide disparities observed in disrespectful and abusive care, the findings of PCMC using quantitative methods show greater consistency and comparability across different settings . This systematic review aims to address this knowledge gap by investigating the level of PCMC in LMICs using studies that used the Afulani PCMC scale .   This systematic review followed the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines . The protocol was registered in the Prospero International Register of Systematic Reviews with ID: CRD42023426638. Information sources and search strategy We conducted a systematic review using peer-reviewed studies. Searches were performed on PubMed/Medline, Embase (Ovid), CINAHL, and Maternal and Infant Care (Ovid) up to 30 May 2023 and updated 26 April 2024. We used medical subject headings (MeSH) and indemnity key terms using MeSH analyser, including: “Adolescen*” OR “adult” OR “middle-aged” OR “young adult” OR “pregnant women” OR “mothers*” AND “Deliver*” OR “childbirth” OR “obstet*” OR “prenatal care” OR “parturition” OR “pregnan*” OR “maternal health services” OR “maternal health care” OR “individual-centred care” OR “patient participation” OR “patient-provider communications” AND “developing countries” OR “low and middle-income countries”. Additionally, we performed hand research or snowball technique using the references of studies included and relevant reviews to identify any further articles uncaptured in this search. Table is presented to show the terms/keywords used for this study. The 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist was used to present the findings on PCMC in LMICs (Fig. ). Eligibility criteria The eligibility criteria for this review included: (i) cross-sectional, mixed-methods, and prospective cohort studies that measured PCMC using the Afulani PCMC Scale (to be consistent in identifying the level of PCMC across countries); (ii) studies conducted in LMICs, as per the World Bank 2023 classification ; (iii) studies conducted in the English language with no time restriction and study population is women. We excluded studies with the modelling of PCMC, personal commentary, review, notes, case studies, conference abstracts and proceedings, press releases, news articles, studies with incomplete information, studies with method problems such as small sample size or with full text not available and reflections and analyses of existing literature. If more than one outcome was reported from a single study each outcome was analysed independently. Study selection Searched articles were exported to Endnote 20, and any duplicates were removed within EndNote. Further screening was conducted by ZYK and AB using title, abstract, and full text. For each eligible study, the author’s name, year of publication, the study aim, country, study design, the PCMC score, and the predictors of PCMC were extracted. Disagreements between the two authors were settled by discussing or bringing additional authors when necessary. Data analysis A narrative synthesis was applied to present the findings. The full PCMC scale has 30 items , with a shorter 13-item version . The 30-item PCMC scale has three sub-scales for dignity and respect (6 items), communication and autonomy (9 items), and supportive care (15 items). Each question on the scale has four response options ranging from 0 to 3, thus generating a score ranging from 0 of 90 for the full 30-item scale, 0 to 39 for the 13-item short version, 0 to 18 for dignity and respect, 0 to 27 for communication and autonomy, and 0 to 45 for supportive care . Quality appraisal Quality appraisal was conducted using the JBI  checklist that contains nine items: sample frame appropriate to address the target population, the study participants sampled appropriately, the adequacy of sample size, the study subjects and the settings described in detail, data analysis conducted with sufficient coverage of the identified sample, valid methods used for the identification of the conditions, the conditions measured in a standard way, reliable way for all participants, the appropriate statistical analysis, the response rate adequate, and if not, was low response rate managed appropriately. Based on the JBI prevalence checklist, the authors assessed the quality of eligible studies, and any disagreements were resolved through discussion and consensus. This systematic review included the studies with quality scores greater than 5 out of 9 total scores (Table ).   We conducted a systematic review using peer-reviewed studies. Searches were performed on PubMed/Medline, Embase (Ovid), CINAHL, and Maternal and Infant Care (Ovid) up to 30 May 2023 and updated 26 April 2024. We used medical subject headings (MeSH) and indemnity key terms using MeSH analyser, including: “Adolescen*” OR “adult” OR “middle-aged” OR “young adult” OR “pregnant women” OR “mothers*” AND “Deliver*” OR “childbirth” OR “obstet*” OR “prenatal care” OR “parturition” OR “pregnan*” OR “maternal health services” OR “maternal health care” OR “individual-centred care” OR “patient participation” OR “patient-provider communications” AND “developing countries” OR “low and middle-income countries”. Additionally, we performed hand research or snowball technique using the references of studies included and relevant reviews to identify any further articles uncaptured in this search. Table is presented to show the terms/keywords used for this study. The 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist was used to present the findings on PCMC in LMICs (Fig. ).   The eligibility criteria for this review included: (i) cross-sectional, mixed-methods, and prospective cohort studies that measured PCMC using the Afulani PCMC Scale (to be consistent in identifying the level of PCMC across countries); (ii) studies conducted in LMICs, as per the World Bank 2023 classification ; (iii) studies conducted in the English language with no time restriction and study population is women. We excluded studies with the modelling of PCMC, personal commentary, review, notes, case studies, conference abstracts and proceedings, press releases, news articles, studies with incomplete information, studies with method problems such as small sample size or with full text not available and reflections and analyses of existing literature. If more than one outcome was reported from a single study each outcome was analysed independently.   Searched articles were exported to Endnote 20, and any duplicates were removed within EndNote. Further screening was conducted by ZYK and AB using title, abstract, and full text. For each eligible study, the author’s name, year of publication, the study aim, country, study design, the PCMC score, and the predictors of PCMC were extracted. Disagreements between the two authors were settled by discussing or bringing additional authors when necessary.   A narrative synthesis was applied to present the findings. The full PCMC scale has 30 items , with a shorter 13-item version . The 30-item PCMC scale has three sub-scales for dignity and respect (6 items), communication and autonomy (9 items), and supportive care (15 items). Each question on the scale has four response options ranging from 0 to 3, thus generating a score ranging from 0 of 90 for the full 30-item scale, 0 to 39 for the 13-item short version, 0 to 18 for dignity and respect, 0 to 27 for communication and autonomy, and 0 to 45 for supportive care .   Quality appraisal was conducted using the JBI  checklist that contains nine items: sample frame appropriate to address the target population, the study participants sampled appropriately, the adequacy of sample size, the study subjects and the settings described in detail, data analysis conducted with sufficient coverage of the identified sample, valid methods used for the identification of the conditions, the conditions measured in a standard way, reliable way for all participants, the appropriate statistical analysis, the response rate adequate, and if not, was low response rate managed appropriately. Based on the JBI prevalence checklist, the authors assessed the quality of eligible studies, and any disagreements were resolved through discussion and consensus. This systematic review included the studies with quality scores greater than 5 out of 9 total scores (Table ).   A total of 888 studies were found in four databases and additional sources, of which 167 studies were removed due to duplications and 684 were excluded based on the title and abstract. A total of 37 studies were considered for full-text screening, and 25 were excluded for reasons such as failure to report PCMC, reporting findings in the abstract and main body were different, and different study population (healthcare providers) and PCMC scale validation. There are two articles within a single study, that were reported outcomes independently. Finally, 12 articles and eleven studies were included in this systematic review (Fig. ). Characteristics of included studies Six studies were conducted in Ethiopia , two studies  and three articles in Kenya , one in Nigeria , one in Pakistan  and one from three countries (Kenya, Ghana and India) . Level of person-centred maternity care (PCMC) We report the total PCMC score, as well as scores for the sub-scales of dignity and respect, communication and autonomy, and supportive care. Eleven studies showed the mean PCMC score during childbirth  and factors associated with PCMC during childbirth. The lowest overall mean PCMC score, out of 39 was 19.07 in Ethiopia , and the highest was 24.2 (SD = 8.4) in Kenya  out of 39 during childbirth at health facilities. Additionally, the lowest overall mean PCMC score, out of 90 was 46.5 (SD = 6.9) in rural Ghana , and the highest was 60.2 (SD = 12.3) out of 90 in urban Kenya  during childbirth at health facilities (Table ). In nine studies, dignity and respect, communication and autonomy, and supportive care were reported  (Table ). Types of PCMC domains This review assessed PCMC subscale such dignity and respect, communication and autonomy, and supportive care. Detailed findings are presented in (Table ) and the following sections. Dignity and respect during childbirth Care with respect and dignity is essential during childbirth. The challenge is maintaining the woman’s dignity while providing women with evidence-based maternity care that supports normalcy, wholeness, and safety for the woman and their newborn . In nine studies, dignity and respect were reported in six LMICs  (Table ). In this review, the minimum score of dignity and respect was 9.95 (± SD = 3.20) out of 18 , while the maximum was reported as 15.7 (± SD = 2.15)  (Table ). Communication and autonomy during Childbirth Essential aspects of PCMC during birthing are effective communication and respect for women’s autonomy . Effective communication and respect for women’s autonomy are essential for healthcare providers to interact with women and ask for their permission before performing any examinations or procedures, to explain to women the benefits of procedures and medications, or to foster an environment where women feel comfortable asking questions about their care during childbirth . In this review, the lowest mean communication and autonomy was reported at 8.3 (± SD = 3.3) out of 27 in Ghana , and the highest mean was reported at 15.87 (SD = 5.44) out of 24 in Nigeria  and 15.5 (SD = 2.39) in Ethiopia out of 27 . Supportive care during childbirth Supportive care is vital during childbirth by providing emotional support, comfort measures, information, and advocating quality of care . It helps facilitate a positive childbirth experience that reduces fear, anxiety, and a resultant side effect . In this review, the mean lowest supportive care was reported at 24.6% (SD = 4.0) out of 45 in Ghana , and the highest was reported at 32.2% (± SD = 6.0) in India . Factors associated with PCMC The results indicated that several factors were associated with an increased mean of PCMC during childbirth at health facilities. These factors included women belonging to a high economic status, women who were literate , married women who delivered their babies at health centres or private health facilities . Conversely, certain factors were found to be associated with lower mean PCMC during childbirth. These factors included experiencing domestic violence , having no ANC follow-up or less than four ANC contacts , delivering babies at higher-level health facilities , women who received assistance during childbirth by unskilled attendants or auxiliary nurses, midwives , undergoing childbirth during night-time , encountering neonatal death , staying in health facilities for 2–7 days , and facing complications during childbirth  (Table ).   Six studies were conducted in Ethiopia , two studies  and three articles in Kenya , one in Nigeria , one in Pakistan  and one from three countries (Kenya, Ghana and India) .   We report the total PCMC score, as well as scores for the sub-scales of dignity and respect, communication and autonomy, and supportive care. Eleven studies showed the mean PCMC score during childbirth  and factors associated with PCMC during childbirth. The lowest overall mean PCMC score, out of 39 was 19.07 in Ethiopia , and the highest was 24.2 (SD = 8.4) in Kenya  out of 39 during childbirth at health facilities. Additionally, the lowest overall mean PCMC score, out of 90 was 46.5 (SD = 6.9) in rural Ghana , and the highest was 60.2 (SD = 12.3) out of 90 in urban Kenya  during childbirth at health facilities (Table ). In nine studies, dignity and respect, communication and autonomy, and supportive care were reported  (Table ).   This review assessed PCMC subscale such dignity and respect, communication and autonomy, and supportive care. Detailed findings are presented in (Table ) and the following sections. Dignity and respect during childbirth Care with respect and dignity is essential during childbirth. The challenge is maintaining the woman’s dignity while providing women with evidence-based maternity care that supports normalcy, wholeness, and safety for the woman and their newborn . In nine studies, dignity and respect were reported in six LMICs  (Table ). In this review, the minimum score of dignity and respect was 9.95 (± SD = 3.20) out of 18 , while the maximum was reported as 15.7 (± SD = 2.15)  (Table ). Communication and autonomy during Childbirth Essential aspects of PCMC during birthing are effective communication and respect for women’s autonomy . Effective communication and respect for women’s autonomy are essential for healthcare providers to interact with women and ask for their permission before performing any examinations or procedures, to explain to women the benefits of procedures and medications, or to foster an environment where women feel comfortable asking questions about their care during childbirth . In this review, the lowest mean communication and autonomy was reported at 8.3 (± SD = 3.3) out of 27 in Ghana , and the highest mean was reported at 15.87 (SD = 5.44) out of 24 in Nigeria  and 15.5 (SD = 2.39) in Ethiopia out of 27 . Supportive care during childbirth Supportive care is vital during childbirth by providing emotional support, comfort measures, information, and advocating quality of care . It helps facilitate a positive childbirth experience that reduces fear, anxiety, and a resultant side effect . In this review, the mean lowest supportive care was reported at 24.6% (SD = 4.0) out of 45 in Ghana , and the highest was reported at 32.2% (± SD = 6.0) in India .   Care with respect and dignity is essential during childbirth. The challenge is maintaining the woman’s dignity while providing women with evidence-based maternity care that supports normalcy, wholeness, and safety for the woman and their newborn . In nine studies, dignity and respect were reported in six LMICs  (Table ). In this review, the minimum score of dignity and respect was 9.95 (± SD = 3.20) out of 18 , while the maximum was reported as 15.7 (± SD = 2.15)  (Table ).   Essential aspects of PCMC during birthing are effective communication and respect for women’s autonomy . Effective communication and respect for women’s autonomy are essential for healthcare providers to interact with women and ask for their permission before performing any examinations or procedures, to explain to women the benefits of procedures and medications, or to foster an environment where women feel comfortable asking questions about their care during childbirth . In this review, the lowest mean communication and autonomy was reported at 8.3 (± SD = 3.3) out of 27 in Ghana , and the highest mean was reported at 15.87 (SD = 5.44) out of 24 in Nigeria  and 15.5 (SD = 2.39) in Ethiopia out of 27 .   Supportive care is vital during childbirth by providing emotional support, comfort measures, information, and advocating quality of care . It helps facilitate a positive childbirth experience that reduces fear, anxiety, and a resultant side effect . In this review, the mean lowest supportive care was reported at 24.6% (SD = 4.0) out of 45 in Ghana , and the highest was reported at 32.2% (± SD = 6.0) in India .   The results indicated that several factors were associated with an increased mean of PCMC during childbirth at health facilities. These factors included women belonging to a high economic status, women who were literate , married women who delivered their babies at health centres or private health facilities . Conversely, certain factors were found to be associated with lower mean PCMC during childbirth. These factors included experiencing domestic violence , having no ANC follow-up or less than four ANC contacts , delivering babies at higher-level health facilities , women who received assistance during childbirth by unskilled attendants or auxiliary nurses, midwives , undergoing childbirth during night-time , encountering neonatal death , staying in health facilities for 2–7 days , and facing complications during childbirth  (Table ).   This systematic review synthesised the level of PCMC based on studies using the PCMC scale during childbirth in six LMICs . The lowest mean PCMC was 46.5 in rural Ghana , and the highest was 60.2 in Kenya  out of 90. In this review, the lowest subscale domain of PCMC was identified as communication and autonomy in Ghana . The low level of communication and autonomy could affect the rapport between healthcare providers and women regarding decision-making and the performance of any procedures, for example, physical examinations, which can decrease the quality of care and be detrimental to women’s future health-seeking. In addition, healthcare providers could get training on communication and autonomy of women and reduce burnout during childbirth to improve effective communication . Additionally, healthcare providers could allow women to make all care-related decisions during childbirth. The lowest dignity and respect subscale of PCMC score was in Nigeria . A low level of dignity and respect for women during childbirth could lead to women and families developing a negative attitude toward maternity care and lessen the quality of care. Similarly, healthcare providers should get training and supervision on women’s rights, dignity, and respect during intrapartum care to improve the quality of care that promotes healthy birth experiences . Furthermore, the lowest supportive care score was reported in Ghana . Improving the lowest level of supportive care during childbirth could be achieved in ways such as allowing companionship during childbirth, emotional support, making the labour ward a conducive environment , and lessening healthcare providers’ burnout. Owing to this, supportive care is crucial for promoting a positive childbirth experience, lowering women’s and families’ fear and anxiety, and minimising any adverse effects that may arise during childbirth . Women who are wealthier, employed, literate, married, and who gave birth in a health centre or private facility  were more likely to get better PCMC. This could be because it is easier for women with higher socioeconomic positions to gain rapport with healthcare providers and get a choice of preferred PCMC. Additionally, women who had ANC and birthing care by the same healthcare providers . This could be because women tend to build cohesiveness with healthcare providers, as they often have more contact with them and are more likely to establish rapport. The finding aligns with a study that demonstrates that women who received midwife-led continuity model care were less likely to require interventions and more likely to be satisfied with the care during childbirth . Women who experienced domestic violence, gave birth in higher-level health facilities , assisted by an auxiliary nurse, midwife, or assisted by unskilled attendant , booked ANC in the second and third trimesters , had no ANC follow-up or follow-up of less than four contacts , stayed 2–7 days in the facilities , experienced complications during childbirth  and neonatal deaths  were less likely to get better PCMC. These findings align with a study indicating that low socioeconomic status significantly increased domestic violence , which could decrease PCMC during childbirth. Moreover, a study reveals that women who experienced midwife-led continuity models of care had lower intervention rates and more satisfaction with receiving care and could increase PCMC during childbirth , while women who experienced care from an auxiliary nurse, midwife, or unskilled attendant significantly decreased the PCMC during childbirth. Women who had experienced complications and neonatal deaths that could lead to psychological trauma  could not effectively communicate with healthcare providers, resulting in lower PCMC. Therefore, the implications of the overall findings show a low level of PCMC between women and healthcare providers and offer a strategy to improve PCMC during childbirth in healthcare facilities in LMICs. This study has limitations. First, our review is based on findings from only six countries, which limits the generalizability of the results to all LMICs. Second, the use of self-reported data on women’s experiences during childbirth introduces potential biases, such as social desirability and recall bias. Women may not accurately recall all their experiences or may hesitate to report negative experiences with care. In exit interviews conducted in health facilities, women might avoid disclosing negative experiences due to concerns about how their future care could be affected. Additionally, research has shown that women are less likely to report negative experiences immediately after childbirth, as the joy of having a baby can influence their responses . Despite these limitations, this review provides valuable insights into the level of PCMC during childbirth in health facilities across LMICs. To the best of our knowledge, it is also the first comprehensive analysis of available data on this topic in LMICs.   Our findings indicated that the communication and autonomy components of PCMC are notably low, affecting the rapport between healthcare providers and women, as well as decision-making and the execution of procedures. Targeted interventions are especially necessary for women who did not receive antenatal care, had extended stays at health facilities, or experienced complications during childbirth. Improving PCMC requires continuity of care through antenatal and intrapartum care provided by the same healthcare providers, alongside fostering a supportive environment for both women and healthcare providers during childbirth. Furthermore, providing training for healthcare providers on effective communication, promoting women’s autonomy, and respecting their dignity is crucial for ensuring the consistent delivery of high-quality PCMC.   Below is the link to the electronic supplementary material. Supplementary Material 1   