Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana

Background: Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives’ perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility. Methods: We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study. Results: The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO’s quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building. Conclusion: We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities. The research team consisted of midwives and nurses (VMD, ABBM, JRL), social scientists (JO), a surgeon (PD) and bio-statistician (PA, EKN). As such, they had no influence over the study participants and overall data collection dynamics. Moreover, interviewers who could speak both Twi and English language and had vast experience in qualitative research interviewing were recruited to support the data collection process. The research assistants were taken through intensive training for three days in order to deal with any conscious and sub-conscious biases that could have compromised the integrity of the study. The interviewers had no direct influence on the study site, methodological procedures, and findings of the study. As a result of this reflexivity exercise, all of the study authors were able to collaborate more effectively since they were able to grasp each other’s perspectives, which added to the study’s rigour. The study adopted an exploratory descriptive qualitative approach. This design allowed us to explore midwives’ perspectives concerning challenges faced and prospects available for promoting RMC by gathering in-depth information through face-to-face interviews. Qualitative exploratory design served as the most appropriate design for this study since we were concerned about gaining broader and deeper insight about the phenomenon under study. Moreover, we adopted this study design because it allows us the flexibility to respond to varied research questions including questions that border on what, why and how the phenomenon under study happens [16]. Purposive sampling technique was used to sample the participants who met the inclusion criteria. The inclusion criteria included the following: (a) participant should have participated in the RMC training, and (b) they should be providing maternity services and willing to participate in the study. In the year preceding the study, midwives at the study site undertook training on RMC. We trained 110 midwives on four separate training period. The training modules taught the trainees how to use effective, alternative birthing positions, focused antenatal care, empathetic and ethical communication with childbearing women, and demonstrating respect and dignity during intrapartum care provision to promote quality intrapartum care free of violence and abuse. Six months after the training, the research team visited the Obstetrics and Gynecology department of the hospital to discuss the study in detail. Two ward-in-charges volunteered as the study’s ‘recruitment links’ Trained research assistants (RAs) visited the hospital to meet with trained midwives through the ward-in-charge as the recruitment link. The study objective was explained to the participants who were eligible, and they were given a copy of the research’s information sheet. We granted prospective participants two-week window to read and review the information sheet in order to guide their decision to either participate or not participate in the study. Midwives with informed decision of participation contacted the RAs via phone for further arrangements on date, time and venue of the interview. Inform consent by writing (n = 11) and thumb printing (n = 1) were obtained prior to the interviews. It was only after the signed informed consent form had been received that our RAs proceeded to start the interviews. The study was conducted in the maternity block of a tertiary hospital within the Kumasi Metropolis in the Ashanti region of Ghana. This facility is recognised as Ghana’s second largest hospital and the only tertiary hospital in the Ashanti region [17]. It provides healthcare to patients across the country but particularly serves the middle and savannah zones of Ghana. As such, it serves as the primary referral hospital for the Ashanti, Bono, Bono-East, Ahafo, Savannah, Northern and North-East regions as well as some neighbouring countries. The facility has a bed capacity of about 1200 and staff strength of about 3000. It has thirteen (13) clinical directorates (departments) one of which is the Obstetrics and Gynaecology (O &G) directorate, which has four labour wards. In 2018, the hospital recorded an estimated 4792 Spontaneous vaginal deliveries, an estimated 123 maternal deaths, and 61 neonatal deaths [14]. The midwife staff strength at KATH is 381. Table 1 provides statistics on the care provided between 2019 and 2021. Statistics on care provided between 2019 and 2021 ABBM, a qualitative researcher with clinical and academic experience in women’s health and maternal care worked collaboratively with three research assistants (RAs) who had undergone a two-days training about the objectives and procedures for data collection for this study, to conduct the face-to-face interviews with midwives. The interviews were conducted using semi-structured interview guide which was developed based on the WHO’s quality of care framework and an RMC module (RMC-M) developed by the first author in her preliminary studies. For each midwife, we approached them and discussed the objectives and procedures for the study. Additionally, their rights as participants were clearly stated to them as well as any possible discomfort, benefits and compensations. After all these have been explained to the midwife, their consent to voluntarily participate was obtained. All interviews were conducted were conducted as a one-off interview, and at a date, time and place of convenience to participants. The researcher and RAs asked probing questions in order to elicit rich qualitative data for analysis. Data collection began on May 1 through to August 9, 2021. On average, interviews lasted about 70 minutes. All interviews were audio recorded after seeking consent from the participants. In addition to the audio recording, the RAs captured other non-verbal cues and gestures through note taking and observation. By the 10th interview, we had reached saturation as no new analytical information was emerging from the interviews. We conducted additional two interviews to confirm that indeed we had gotten to the point of data saturation. We did not encounter any situation where participants refused to participate in the study. Also, none of the participants dropped out at any point in the study. Ethical approval was obtained from the Committee on Human Research, Publication, and Ethics (CHRPE) at the Kwame Nkrumah University of Science and Technology (KNUST) (reference number: CHRPE/AP/181/18) and the Komfo Anokye Teaching Hospital (KATH) Institutional Review Board (reference number: RD/CR17/289). We anonymised information by giving pseudonyms to the participants in order to protect their identities and prevent third parties from tracing data back to participants. Written informed consent was sought from participants in order for them to voluntarily participate in the study after having read and understood the terms, risks and benefits associated with their participation. Also, the recorded interviews were encrypted to prevent third parties from having access to it. Interview venue (Office at KATH), date and time were determined by the participants. Interview language was Twi (local language). Both the interviewer and researchers could speak and understand Twi on a full professional competence level. The audio files from the interviews were transcribed verbatim. ABBM proofread the transcribed interviews alongside listening to the audio files as a way of ensuring that, the transcripts reflected exactly what the participants stated. Two independent translators fluent in both the Twi and English languages then translated the twelve anonymised “Twi” transcripts using the process of back-back translation while maintaining confidentiality. Independent thematic coding analysis using QSR NVivo-12 was performed by two data analysts (PA and JO). Translated transcripts were imported into NVivo-12 for data management and analysis. Codes were generated through inductive analysis to create themes and sub-themes. This inductive analysis was done by reading the raw text data and discussing the emerging issues to form themes. Significant recurrent statements or phrases were retrieved as codes from participants’ transcripts to provide data that directly relate to the issue under research. The relevant statements or phrases were then used to develop formulated ‘meanings’ that described and illuminated the obstacles and opportunities for promoting RMC. Following that, themes were created based on various statements with comparable meanings. This process was repeated for all the 12 transcripts. Insights from the transcripts were broadly presented in line with the main questions in the semi-structured guide. To completely develop the ideas, the original themes were followed in subsequent interviews and validated using field notes. The initial analysis was performed by PA and JO, and later validated by the first, second, and third authors and through member checking with five participants. These participants reviewed the printed transcript so as to confirm the accuracy in the presentation of their views. Member checking allowed us to confirm the findings from our analysis. However, none of the issues changed after member checking. Recognising the worth of rigour and trustworthiness in qualitative research, we ensured that our study and its methods adhered strictly to the principles of credibility, confirmability, transferability, and authenticity. Transferability was ensured by giving detailed description of the study objectives, research design, data collection procedures, study contexts and data analysis procedures. Confirmability was ensured by allowing five of the participants to review the printed transcript so as to confirm the accuracy in the presentation of their views. To authenticate the results, completed interviews were first reviewed by the interviewers. After that level of review, VMD, who is project lead and an experienced qualitative researcher together with ABBM and EKN validated the results. To ensure credibility, we adhered strictly to the study protocol and ensured that audio data were transcribed verbatim.