Overcoming barriers and harnessing facilitators: Respectful maternity care in least-developed countries

Abstract

Background

Disrespectful care violates women’s rights, delays care-seeking and contributes to preventable adverse birth outcomes. Although Respectful Maternity Care (RMC) is a key strategy for improving maternal and neonatal health, evidence on factors affecting its implementation in least-developed countries remains poorly synthesised.

Objective

To assess the barriers and facilitators of RMC in low-income countries.

Design

Systematic review synthesising evidence from qualitative and mixed-methods studies was conducted.

Data sources and methods

A systematic search was conducted across major databases, including Scopus, Web of Science, PubMed, CINAHL, and Embase. Eligibility criteria were defined using the SPIDER framework. Studies published between 2015 and 2025 were included. Methodological quality was assessed using JBI SUMARI for qualitative studies and the QATSDD tool for mixed-methods studies. SPIDER framework was applied to support eligibility criteria. The review followed PRISMA guidelines. The data were synthesised using thematic analysis and applied to the Socio-Ecological Model.

Results

Forty-eight studies conducted in least-developed countries were analysed, consisting of 36 qualitative studies and 12 mixed-methods studies. Barriers and facilitators to RMC were identified at individual (knowledge, attitude, skills), interpersonal, organizational (resources, infrastructures), policy (guidelines, education), and socio-cultural level (norms, cultures).

Conclusion

Strengthening RMC is crucial for reducing maternal and neonatal mortality. The review highlights the need for supportive policies, improved infrastructure, and targeted provider training. Future research should develop and validate context-specific RMC principles and indicators to strengthen providers’ understanding and skills for practice in least-developed countries.

Registration

The protocol was registered with PROSPERO (CRD42023443998).

Plain language summary

This review examined what facilitates and what challenges respectful maternity care (RMC) in least-developed countries. After analysing 48 studies, the review found that barriers and facilitators exist at multiple levels, including individual knowledge and attitudes, relationships between care providers and patients, health facility resources, national policies, and wider cultural norms. Strengthening RMC is essential to reduce maternal and newborn deaths. The review highlights the need for better policies, improved health system infrastructure, and targeted training for healthcare providers. It also recommends developing RMC guidelines and measures tailored to the local context.

Keywords

barriers facilitators “least-developed countries”“respectful maternity care”

Introduction

Despite global improvements, adverse childbirth experiences and preventable maternal deaths remain concentrated in low-resource settings.¹ In 2023, the global maternal mortality ratio (MMR) was 223 per 100,000 live births, with 60% of these deaths occurring in low-income countries (LICs), particularly in Sub-Saharan Africa.² These rates exceed the Sustainable Development Goal target of fewer than 70 deaths per 100,000 live births by 2030, requiring a much faster annual decline than currently observed.³ Respectful Maternity Care (RMC) is recognised as a key strategy for improving maternal health outcomes and reducing mistreatment, and is strongly endorsed by the World Health Organization (WHO).⁴

WHO defines RMC as the care that safeguards a woman’s dignity, privacy, and confidentiality, ensures protection from harm and mistreatment, and facilitates informed choice and continuous support during the perinatal period.⁴ This person-centred care should be provided for all women, gender-diverse people, neonates, and families.⁵ RMC has also been found to be a significant indicator of maternal and newborn health improvement.^4,6 However, the global provision of RMC remains inadequate, with around 54% of women experiencing mistreatment during childbirth.⁷ This indicates that mistreatment of women during childbirth is a global concern affecting healthcare systems.⁸

Most incidents of mistreatment occur in LICs, where limited resources, awareness, and insufficient data hinder the advancement of RMC.⁹ Recent studies conducted in LICs regions shows that women often face insensitive, harsh, disrespectful, or abusive treatment during childbirth.^10,11 Evidence from Sub-Saharan and Eastern African countries indicates that nearly half of women giving birth in healthcare facilities experienced mistreatment.^12,13 A study conducted in four low resource countries found that 41.6% of women (n = 2,016) observed during labour and childbirth in healthcare facilities experienced physical or verbal abuse and discrimination based on personal attributes.¹⁴ This study also reported that often procedures like caesarean sections, episiotomies, and induction of labour were performed without consent.¹⁴

Mistreatment harms women psychologically, physically, erodes trust and communication, normalises poor treatment, limits informed decision-making, and is linked to poor obstetric outcomes.^15–17 Such mistreatments undermine women’s relationships with their newborns, families and future contact with health care services.^14,18 These negative experiences often lead to reduced engagement, compromised decision-making autonomy, and ongoing feelings of disrespect.¹⁹

Understanding the factors that contribute to women’s negative experiences is essential for advancing RMC.⁵ WHO categorises factors influencing RMC into policy-related, sociocultural, organizational, and individual drivers.⁵ These factors can be further understood using frameworks such as the Socio-Ecological Model (SEM), which examines how personal, social, and environmental influences interact to shape practice.²⁰ The model highlights multiple levels of determinants, intrapersonal, interpersonal, institutional, and broader environmental or societal factors and suggests that changes can promote positive experiences.²⁰ Successful implementation of RMC in LICs requires a clear understanding of the drivers of RMC, as perceived by both the women receiving care and the healthcare providers delivering it.²¹ Although a substantial body of research addresses this topic, the drivers of RMC in least-developed countries have not been comprehensively synthesised.

Review aim

This systematic review aims to synthesise primary studies to answer the question, “What factors facilitate or impede RMC implementation in least-developed countries from the perspectives of women and healthcare providers?”

Methods

The reporting of this study conforms to the PRISMA guidelines.²² This systematic review followed the JBI approach for qualitative systematic review.²³ The protocol was submitted to the PROSPERO database (International Prospective Register of Systematic Reviews) with the registration number (CRD42023443998).

Theoretical framework

We applied SEM to assess barriers and facilitators of RMC in LICs.²⁰ The SEM provides a structured approach for examining individual, interpersonal, organizational, and community factors across diverse settings.^20,24 This model has been used by WHO in their compendium of RMC, which assessed factors affecting RMC; in a systematic review on the barriers and facilitators to maternal healthcare in East Africa²⁵; a study on negative childbirth experiences of Dutch women²⁶ and studies that explored women’s and care providers’ perspectives on mistreatment during childbirth.^27,28

Although other frameworks such as the Theoretical Domains Framework (TDF)²⁹ and Normalisation Process Theory (NPT)³⁰ could be used to explore drivers of RMC, they have limitations. TDF focuses on individual behaviours but lacks a systems-level perspective,²⁹ while NPT examines social processes but does not fully address external policies, organizational structures, and cultural factors.³⁰ Therefore, in this review, the SEM is the most suitable framework compared to other theoretical models. The detail is presented in Figure 1.

Figure 1.

Socio-ecological model to study drivers of RMC in least-developed countries.

Eligibility criteria

The SPIDER framework³¹ were used to identify studies and apply eligibility criteria. Qualitative and Mixed-methods studies were included. Mixed method studies were included if the qualitative data could be retrieved. Studies were selected based on their publication in peer-reviewed journals and in the English language. The review included studies on respectful and disrespectful maternity care from 2015 to 2025. Finally, studies were restricted to those conducted in the least-developed countries.³² The detail is presented in Table 1 below.

Table 1.

Eligibility criteria of studies include in this systematic review.

Framework	Inclusion criteria	Exclusion criteria
Sample	All pregnant or postpartum women regardless of their gestational age status and mode of birth. maternity care providers (Midwives, Nurses, General practitioners, Obstetricians, Gynaecologists)	Women seeking other maternity services (preconception or abortion). Students and maternity care providers who had worked less than six months
Phenomena of interest	Respectful maternity care	Other aspect of the care
Design	Interviews, focus groups, ethnography	Case studies, survey
Evaluation	Barriers and facilitators to implementing RMC	Effectiveness of RMC, impact of RMC interventions
Research type	Qualitative studies (phenomenology, grounded theory, ethnography, action research, and descriptive) and mixed studies and mixed methods	Quantitative, case study, editorial letters, reports, books, non-peer-reviewed, reviews (their reference lists will be checked), dissertations or theses, case reports, and conference papers

Search strategy

The search strategy comprised specific headings, MeSH, keywords, and free text search terms, with truncation and wild cards to enhance sensitivity across each database. The strategy involved searching for primary articles based on the eligibility criteria. Initially, a preliminary search was conducted on PubMed to locate relevant publications. Scopus, CINAHL, Embase, PubMed, and Web of Science were systematically searched. To identify additional relevant studies, we also manually reviewed the reference lists of included papers. An example of the search strategy using the keywords found in the titles, abstracts, MeSH, and index terms of pertinent publications is available in the supplementary files (Supplemental file S1). The reference list of each study selected for critical appraisal was examined for additional relevant research.

Study selection

All identified citations were first uploaded to EndNote and then imported into Covidence, where duplicates were removed.³³ Subsequently, two independent reviewers screened titles and abstracts to determine whether they met the eligibility criteria. Potentially relevant articles were retrieved, and full text articles were imported into the Covidence system.³³ Two independent reviewers carefully evaluated the complete text of chosen citations against the inclusion criteria. Any conflicts or discrepancies between the two primary reviewers were resolved through discussion with a third reviewer. A Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (see Supplemental file S2) was used to illustrate the search results in the final report, including a comprehensive description of their findings.²²

Assessment of methodological quality

The standardised critical appraisal instruments from JBI SUMARI were employed to evaluate the methodological validity of the qualitative studies.³⁴ The overall score was assessed on a scale of ten, with the range of 8-10 being deemed as high quality, 4-7 as fair, and 0-3 as low quality (Supplemental file S3). The Quality Assessment Tool for Studies with Diverse Designs (QATSDD)³⁵ was utilised for quality assessment of mixed method studies. This tool was selected due to its good inter-rater reliability (k = 71.5%) and ability to highlight the methodological strengths and weaknesses of studies.³⁵ The QATSDD offers a range of scores, where 0 to 14 indicates a low-quality study, 15 to 28 indicates a moderate or fair quality study, and 29 to 42 indicates a high-quality study³⁶ (Supplemental file S3). In instances where additional information was required for clarity, the authors of the paper were contacted. Discussion between reviewers enabled consensus.

Data extraction

The standardised JBI data extraction tool³⁴ was used by two independent reviewers. Extracted data included the title, authors, country, and publication year of each study. Information on the population, study method, sample size, context, setting, and culture were also collected. Additionally, data on enabling or facilitating factors, impediments or barriers were extracted. Qualitative data themes or subthemes with corresponding illustrations were assigned a credibility level.

Data synthesis

Data were synthesised using the SEM as a framework.²⁴ Subthemes were first developed by grouping findings with similar meanings, and these subthemes were then organised into broader themes.³⁷ Each theme was mapped onto the appropriate domain of the SEM (individual, interpersonal, institutional, health system, and sociocultural).²⁴ Supporting the SEM, this review used Bohren et al.’s (2015) evidence-based framework to define key aspects of RMC.³⁸ The Bohren et al. framework identifies seven interconnected domains of mistreatment during facility-based childbirth: physical abuse, verbal abuse, sexual abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints.³⁸ This structured approach ensured consistency and accuracy in interpretation, strengthening the quality and reliability of review findings.

Results

Search results and study characteristics

The search retrieved 12,058 articles from the following databases: Scopus (n = 2,514), PubMed (n = 2,910), Web of Science (n = 2,821), CINAHL (n = 2,401) and Embase (n = 1,405). Seven references were sourced through citation search (n = 7). After identifying and removing duplicates (n = 6,927), a total of 5,131 titles and abstracts were screened, leading to the exclusion of 4,916 irrelevant studies. Consequently, 215 studies were selected for full-text analysis. Forty eight studies satisfied the inclusion criteria, comprising 36 qualitative studies,^{27,28,39–72} and 12 mixed methods studies.^73–84 The detail is presented in Figure 2.

Figure 2.

PRISMA flow chart of the article selection for barriers, and facilitators of respectful maternity care in low-income countries, 2025.

The review included studies from Ethiopia (n = 20), Tanzania (n = 9), Afghanistan (n = 3), Malawi (n = 4), Zambia (n = 2), Madagascar (n = 1), Mali (n = 1), Mozambique (n = 1), Rwanda (n = 1), Uganda (n = 1), Zimbabwe (n = 1), Guinea (n = 1), Myanmar (n = 1), Zambia and Mali (n = 1) and Zambia and Tanzania (n = 1). A summary of findings is presented in Supplemental file S4.

Quality appraisal results

Overall, most studies demonstrated moderate to good quality. Nine mixed-methods studies and twelve qualitative studies were rated as high quality. The review team used an inclusive appraisal approach to capture strengths and limitations, enhancing the reliability of findings. Detailed scoring for each JBI SUMARI and QATSDD domain was provided in Supplementary File S3.

Barriers and facilitators of RMC implementation in low-income countries

Drivers (barriers and facilitators) were categorised according to the SEM at individual, interpersonal, institutional, policy and socio-cultural levels. Barriers of RMC are detailed in Table 2 and facilitators are presented in Table 3.

Table 2.

Barriers of RMC implementation in least-developed countries, 2025.

Domain	Theme	Codes	Concepts	Participants’ voice	References
Individual level barriers	Women reported barriers	Low health literacy	• Low awareness of basic rights	“[It is] very important that the doctors tell [us] how everything is instead of just writing as some of [us] are illiterate.” ⁵⁰	^{27,40,50,54,66}
		Low health literacy	• Low awareness of RMC principles	“I think that health care providers were allowed to do a physical examination on us without asking our permission … I could not refuse them when they did physical examinations on me during labour because I thought it was their right. For instance, six health care providers physically examined me while I was in labour”. ⁶⁶	^{27,40,50,54,66}
		Cultural beliefs and practices	• Lack of consideration for taboo fady and cultural prohibitions	“It is our ancestors who created this taboo [fady], it comes from them. If you give birth and the baby does not survive then they (the babies belongings) will not be used. That’s why the parents refuse to prepare the baby things…. When the baby is born and healthy in your arms, that’s when you can buy the stuff”.⁴³	^{27,43,57,58,80}
		Cultural beliefs and practices	• Disrespect due to cultural practices	“…. The issues of tradition and customs is not given due weight. I personally do not care... I work as I was trained …She may perform her traditions and customs when she goes back home. I have not asked any mother about her observance regarding childbirth… ”). ⁵⁷	^{27,43,57,58,80}
		Normalised disrespect and abuse	• Fear of retribution of care providers	… When I asked about (vaginal examination) she told me to mind my business… ‘your business is the labour pain. Mine is to monitor you. Even if I tell you, will you know what it means?’ I was so scared of asking anything. I delivered a female stillbirth. (Woman, Zambia). ⁵²	^{40,46,52,61,66,72}
		Normalised disrespect and abuse	• Internalisation and normalisation of the disrespect and abuse	“It is ok if a provider pinches or slaps a woman on her thigh and encourage her to push. Developing complications or loss of a baby is more painful than being slapped or pinched…” (Woman).⁴⁰	^{40,46,52,61,66,72}
		Uncooperativeness	• Perceived as demanding and uncooperative	“The women that say we slap them or yell, are the ones that don’t collaborate. Even yesterday a mother was closing her legs and I lost control because the baby was suffering. I yelled at her: did you carry a baby for nine months to end up here closing your legs?” (Midwife). ⁴⁶	^{46,61,72,73,78,81}
		Uncooperativeness	• Non-compliant with rules, decision making, and providers’ instructions	“Some women don’t understand that we are understaffed. They want that individualised or personal care, forgetting that this midwife is alone and attending to many women in labour.” (Care provider). ⁸¹	^{46,61,72,73,78,81}
	Care providers identified barriers	RMC practice	• Gap between RMC principles and actual practice	“The real care is not there in this hospital. When one delivers in the labour ward, instead of cleaning you and help you to dress up since you do not have enough energy, they leave you to do it yourself and that does not care.” (Woman). ⁴⁴	^28,44,49,50
		RMC practice	• Poor adherence to universal RMC principles	“….it is very, very difficult to give respectful care ...in the labour ward, it is difficult; there are ten rooms and sometimes it happens that there are only four of us. How can we manage those rooms?” (Healthcare provider). ⁵⁰	^28,44,49,50
		Knowledge of RMC	• Lack of understanding of RMC principles	“Because I don’t really understand [when] you [say] ‘Respectful [maternity care]’ … I don’t think I’ve ever heard that kind of thing” – (Healthcare provider). ⁵⁰	^{28,42,49,50,81}
		Knowledge of RMC	• Lack of understanding of RMC principles	‘It [disrespect and abuse] happens – sometimes you might not even realise that you are doing it’ (Midwife). ⁸¹	^{28,42,49,50,81}
		Attitude towards RMC	• Perception of no need of pain relief during childbirth	“… Why would I waste my time and energy explaining everything to her then? Even if I have the training and materials it takes to do so, I am not doing it because I attend more than one woman at a time, and it is not convenient.” (Midwife). ⁵⁶	^{46,51,53,56,61,64–66,78,80,81}
			• Providers often overlook respectful care due to expectations or prejudice
			• Perceived lack of necessity of RMC provision.	“Threatening a woman with poor outcome for her or her baby has no harm and will make her cooperative….” (Midwife). ⁵⁶
			• Unwilling to implement RMC	“Most important thing is to deliver a live baby…not respect... There are two things [that are the worst for a provider]: maybe maternal death, then we have stillbirth.” (Midwife). ⁶¹
			• Fear of bad birth outcomes
		Professional care standards misconduct	• Poor work ethics	“When they wanted to see your private parts, they would do it with the other nurses looking at you…. If you tell them to keep the curtains properly, they will ask you in a harsh tone, ‘are you reminding me of my duties?’ I feared that it would trigger their anger and mistreat me more.” (Woman). ⁵²	^{28,39,43,45,48,49,51–53,58,59,61,62,66,74,76,80}
			• Unconsented care
			• Breach of confidentiality
			• Neglect or long delays in women’s needs
			• Absence of skilled attendant during birth
			• Physical abuse (restraint, painful procedure/beatings/slapping/pinching, fundal pressure)	“We need workers who use work ethics and good working culture as they deliver their duties. Most health workers… they shout at patients and our mothers and use inappropriate language. Most of the health workers are there to earn a living. Nursing is not a calling anymore. Our women are not respected.” (Stakeholder, Zambia). ⁵²
			•Verbal abuse (harsh language, judging, threat, blaming, insult)
			•Stigma and discriminations based on marital status, age, ethnicity, economic status, literacy, occupation, medical conditions, place of birth, parity, residence, prioritizes family, relatives, rich women.	“When we are doing an episiotomy, the mother may want to stand and try to leave the room, in such cases, we may kick the women by scissor…” (Midwife with 6 years’ work experiences). ⁴⁵
			• Poor feto-maternal condition monitoring	“A nurse said ‘how can someone have all these children? How many times will I preach about family planning? Are you deaf” (touching my ears). You will be the last to be seen. She kept on referring to me as ‘the one with 13 pregnancies!’… I was humiliated.” (Pregnant woman). ⁵²
		Employee dissatisfaction	• Lack of commitment and recognition.	“Sometimes, you keep on doing and discharging your responsibilities… but no one from the senior managers comes to you and sees what you do and gives you recognition.” (Care provider). ⁴²	^{28,39,41–43,45,46,49,56,59,75,76,80}
			• Low salary and incentives
			• Dissatisfaction with work environments
			• Low risk allowance payment	“We are doing the hard job at the frontline, but I do not feel valued as a professional and this has demotivated me.” (Midwife). ⁵⁶
			• Undefined career path
			• Delays in remuneration	… a woman died in our ward. Her family abused me physically to the extent that I had bruises all over my body. I complained to the head of the hospital. He said: “go away, it’s normal to be slapped by people.” ⁷⁶
			• Feelings of frustration, powerlessness, stress, fatigue, burnout
			• Blaming midwives for poor health outcomes
			• Not expressing gratitude for services	“Most patients don’t appreciate our work. They blame us for all their bad experiences with hospitals; it is all our fault.” (Midwife). ⁴⁶
Interpersonal level barriers	Defective women provider relationship	Ineffective communication skill	• Minimal quantity of communication	“… workload might be a challenge to quality of the communication …. some [providers] are skilled communicating women, and some [providers] might lack that skill.” ⁷³	^{27,28,39,43,46,54,56,58,59,61,73,76,77,80}
			• Lack of understanding check
			• Neglect requests of women
			• Mistrust	“Those nurses, even if you tell them, they don’t care … because when you tell them, they don’t really concentrate on what you are telling them, they are just doing their business and just looking at you as if you are nothing...” (woman). ⁶²
			•Poor interaction with women
		Controlling women’s choices	• Lack of respect for women’s preferences	“The decision-making process should come from [me] … We are the ones experiencing the pains and enduring the whole process. So, doctors should only be there to advise or help [us].” – Woman. ⁵⁰	^{40,44,50,56,58,67,76}
			• Denial of safe traditional practices
			• Denial or lack of birth companions
			• Frustrated relationships	I am the professional and I am the only right person to decide on procedures. What do the woman, or her family know about the care that I ask them for a consent? (Midwife, urban hospital). ⁵⁶
			• Poor support from healthcare providers
		Power dynamics	• Power imbalances and authority over women	“We do everything in our power to disallow companions. Because we do not want the companion to see how we treat the woman in the delivery room. I am not confident our practice is in line with the national guideline. However, if she is alone, you can do whatever you like in peace. She is in your hand” (Midwife). ⁵⁶	^{27,28,54,56,62,63,66}
			• Justifications for punishments and rewards
			•Viewing women as learning objects	“To learn skills, the health care provider conducted vaginal examinations on me. How can a stressed-out mother be turned into a teaching tool? How is it possible that this practice happens in a hospital where mothers are encouraged to give birth? I don’t want to go through anything like that again in my life”. (Woman). ⁶⁶
	Defective providers relationship	Weak care providers collaboration	Inequalities between professionals. Weak teamwork	“The health [team] is teamwork in general. Having only a doctor, or only a midwife is not effective. When a woman comes [to hospital] she sees white gowns she does not differentiate who is doctor, who is midwife, who is nurse. She expects to be treated and taken care of by all. So, the supervisor should make sure that all workers play their role. Someone should take the woman to the ward, someone should give her health education, even the guard and cleaner should guide her. Otherwise, women will be discouraged and not come again.”	^27,28,70
Organizational related barriers	Shortage of facilities and resources	Poor condition of health facility and lack of resources	• Poor quality and cleanliness	“… I gave birth in the waiting room because there were only three delivery coaches. All maternity care users and health care providers were watching me while I was giving birth in a waiting room. They exposed my privacy to all strangers to watch me. Starting from that day, I feel disappointed on the labour and delivery service of hospitals”.⁸⁰	^{27,28,39,42,47,49,50,52,54,57,59,62,66,67,73,77,80}
			• Dysfunctional showers and sinks
			• Shortage of water supply
			• Lack of waiting area
			• Poor light and ventilation
			• Overcrowded wards with medical students
		Resource constraints in healthcare	• Lack of medications, basic consumables, infection prevention supplies, blood packs, essential medicines, foetal monitoring equipment.	“I am not happy with the working environment at all. It is stressful to work in a ward that is narrow, understaffed and has a shortage of medical supplies. I yell at women to takeout my anger, I am not happy.” (Midwife. ⁵⁶	^{39,41–43,45,47–50,52,56,58,59,63–67,73–75}
		Budgetary system issues	• Long procurement procedures.	“We have allocated a budget for the purchase of supplies. However, it is tough to get these in the market. How could I admit a woman for labour when I do not have a glove to use? A mother will get referred without her will and consent …” (Hospital manager) ⁴²	^{39,41–43,45,47–50,52,56,58,59,63–67,73–75}
			• Low-quality medical equipment supply.
			• Financing issues: fee-exemptions, insufficient budget release.
		Provider incentives issues	• Low incentives for providers.	“Our monthly payment and workload are not proportional; often this will annoy you because life is very costly, and you can represent your anger on your customers. The salary and the workload never fit.” (Midwife).⁴⁸	^48,59
		Provider incentives issues	• Inadequate compensation and recognition for staff.		^48,59
	Systemic barriers	Unethical facility culture	• Bribery, extortion, unclear fee structure.	“We learnt through the media and government outlets that maternity services are free of charge, but they wanted to make me pay for the bed. … after a lengthy argument that they decided to just let my wife get a free bed” (partner). ⁵⁸	^{39,43,46,49,52,54,57,58,76}
			• Direct and indirect costs: transportation, medicine, consumables, equipment.
			• Avoidance of family companionship
			• Poor facility readiness	“… if she (women) asks us to get her attendant in, it is impossible. If she wanted to drink water, I would do it by myself.” (nurse) ⁵⁴
		Delays access to maternity services	• Long waiting times	“...We have transport [ambulance], but it has its challenges too…. We don’t have enough fuel …., so patients are supposed to pay for fuel. They don’t like it, but what else can we do, they feel like we are denying them their rights”. ⁴⁹	^{49,50,52,58,62,64,65,74,76,80}
			• Delay providing care
			• Lack of reliable transport
			• Delay in referrals
			• Unavailability of specialist care	The patient waited in the birth room for around two hours, but she was not transferred to the PNC room. The midwife didn’t encourage her to stay for post-birth observation and she directly left the hospital. ⁷⁶
		Inadequate health workforce	• Underqualified staff	I hear the nurses at our facility are not midwives. We also need trained personnel here in the village. They take all qualified personnel to big hospitals and give us people who are not very competent to handle pregnant women, it is not fair. (Pregnant woman, Zambia). ⁵²	^{39,41,42,46–52,54,59,62,64–66,73–77,80}
			• Poor rostering leading to high workload
			• Low number of midwives
			• High service provider turnover	“Many workloads… we became tired and were not in good mood.” [Doctor]. ⁵⁴
		Disorganised management system	• Lack of accountability and ethical practices	“There is no regular support from our higher officials rather than asking for a monthly report. We also not enrolled in long as well as short-term training”. ⁸⁰	^{39,41,46,49,56,59–61,66,76,80}
			• Inadequacy in binary thinking and problem-solving
			• Responsibility and carelessness	“The management is not fulfilling what we want to do in our work. That is why I feel my profession is neglected. To be respectful, I must be respected first.” (Midwife).⁵⁶
			• Insufficient support for healthcare providers
			• Inaction on staff concerns
			• Lack of emotional empathy and authoritarian approach
Policy related barriers	Policy shortage in healthcare	Lack of guidelines, policies, and standards	• Lack of updated guidelines, lack of national guidance, clinical algorithms and guidelines lacking clarity and absence of responsible body for reporting disrespect and abuse	There are clinical algorithms and guidelines, including visual cues in the facility, but nothing which provides clear guidelines for how to give … respectful care (Study from Zambia). ⁶¹	^39,59,61,73
	Poor education and professional development	Career challenges	• Undefined career path	“The doctor tells the midwives how dare you do episiotomy and how dare you to use vacuum. The one who has higher position, insults the others in front of the patients. Despite our good behaviour and respect, they don’t allow the midwives to conduct examinations. The work environment doesn’t let us to be independent. Yes, when you don’t have the authority, your attitude will be bad with the patients.” ⁷⁶	^{42,46,56,76,80}
			• Limited scope of practices
			• Professional inferiority and superiority complex
			• Lack of professional supervision
			• Weak professional association	“Even our own hospital discriminates between doctors and midwives. Their room for refreshment is much better equipped, they always have water, and the food is much better than what we get.” (Midwife). ⁴⁶
		Midwifery training quality issues	• Lack of continuous profession education	“I have 5- service years in the health centre with a diploma midwife. There is no growth in salary as well as my educational status. This makes me even to dislike my profession at all.” ⁸⁰	^{48,51,75,76,80}
			• RMC topic is not included in pre-service curriculum
			• Neglect of respectful care in training	“The head of the hospital does not count on midwife. He sends for workshops whomever he likes. I have been working here for four years but he has never sent me for workshop. Another midwife went to a workshop on the second day of her recruitment….” ⁷⁶
			• Lack of updated trainings	“… Our midwifery education did not include compassionate and respectful care, and most of us did not receive it as part of our in-service training.”(midwife) ⁴⁸
Socio-cultural related barriers	Socio-cultural norms and gender dynamics	Patriarchal norms and social status	• Civil war, ethnic, religion-based violence.	When the patient’s condition becomes worse, they blame the midwife and talk offensively. … health providers are threatened by guns. The people have guns here, and they speak with guns not with tongues. ⁷⁶	^{27,28,62,63,68,76}
			• Security concerns.
			• Acceptable violent interactions.
			• Perception of women’s low social status.	” The environment is not secure. Even they threatened me against coming to work. But I am coming. Because I need money and, I think about mothers. Most of the people don’t count a woman as a human. They don’t let them go out. There are kidnapping cases of children. The women are scared their children will be kidnapped if they go out.” (Midwife from Afghanistan). ⁷⁶
			• Normalised disrespect and abuse in society
		Cultural and religious beliefs	• Choice of birthplace and mode of birth	“If I delivered normally, I didn’t have the plan to deliver at the hospital. My mom also said to deliver at home as they were around me. My friends also delivered at home. As for me, it was the first baby and it was up right position, I was afraid and delivered at the hospital.” [ 29 years old urban woman]. ⁵⁴	^39,49,54,61
			• Pain seen as natural birth experience
			• Male providers often rejected due to religious beliefs.	“ … recently I was just walking around and I overheard people [males] saying that these male health providers are just looking at our wives genitals, and another one said, they also put their fingers into their private parts…” (Midwife). ⁴⁹
	Social disparities and structural inequalities	Poor family support	• Lack of companionship and support from the family	Family companions expected to care for women (food, drinks, change of clothes, prayer, and encouragement), clean up after the birth, listen to explanations from providers, communicate this information to other family members, and obey the rules of the health facility. ⁵⁴	^27,54
		Language and interpretation issues	• Inability to read and write	“I did not go to school, so sometimes I don’t understand what the nurses are saying. It is even worse when the nurse mixes English and Chichewa in her discourse. Now the frustrating thing is that when I want to ask for clarification, I am shouted at and at times stopped or denied any opportunity to ask questions. This is why in my first pregnancy I decided to deliver at a traditional birth attendant because there she never shouted at me. She was more caring than the nurses here who take advantage of our illiteracy”. ⁵³	^50,52,53
			• Inability to speak provider’s language.
			• Lack of translator

Table 3.

Facilitators of RMC implementation in least-developed countries, 2025.

Facilitators of RMC implementation in low resourced countries
Theme	Codes	Concepts	Contribution studies
Healthcare Providers related facilitators	Knowledge	Midwives’ knowledge, practice, and ongoing education on RMC	^59,64
	Attitude	Favourable attitude towards RMC	^50,55
	Gender difference	Care received from male midwives; female midwives normalised pain	³⁹
	Motivated staff	Highly committed and motivated staff, caring against the odds (resource constraint)	^41,52,79
	Behaviours	Compassionate and respect-based behaviour, empathy, listening, and benevolence, attention and talking lovingly with women	^43,44,48,55
Institutional norms, support, and practices	Continuous support for the women	Continuous support during childbirth, as well as physical space and emotional support, care providers proximity to women	^57,58,62
	Respect for women’s autonomy, confidentiality, and privacy	Humanising birth care by putting women at the centre, respecting their privacy, enabling informed choice, good information sharing and collaborative care and shared decision making	^{44,50,55,57,58,60}
	Dignified and respectful care	Using friendly welcome and courteous language, provide abusive free care	^{48,55,58,60,67}
	Good quality of care	Provision of safe and timely maternity care, active engagement in women’s labour process	^55,60,67
	Enabling environment	Continuous supportive supervision for care providers, being held responsible and accountable, improved facility infrastructure, supplies, supportive mentoring, improving staff number and create good working environment, increased wages, and increased care provider’s time to rest.	^{42,46,55,79,81}
	Midwives’ professional identity and role in society	Pride in being midwife: High responsibility, bringing new life and joy	⁴⁶
	Community Engagement and Advocacy	Outreach activities and campaign, and health education. Empowering women, service providers, community health workers, communities, and policymakers with the knowledge and skills to tackle disrespect and abuse during childbirth	^49,65
Inter-personal relationships	Mutual understanding	Trusting relationships formed with labouring women, and holistic care, positive interactions between midwives and women	^48,53,60
	Effective communication	Good communication skills	^48,50,58,62
	Mother and baby bondage	Encouragement of the mother-baby relationship during postnatal period, encouraging breast feeding, counselling about immunisation, hygiene, danger sign, contraceptives, etc.	⁶⁰
	Birth companion	Witness good care, calm the women, monitor the women, and belief in the benefit of having family become active participants during childbirth	^46,57
Educational capacity buildings	Awareness creation about RMC Training Workshops	Increased sensitisation and training of midwives on RMC. Stand-alone RMC Workshops at health facilities and community levels, along with ongoing refresher training and health education for women	^{42,57,64,65,75,77,79,81,85,86}

Individual barriers

Women-identified barriers

Women’s limited health literacy and lack of awareness of their rights contributed to mistreatment.^{40,50,54,66,75} Lack of consideration for their culture and traditions by staff exposed many women to disrespect.^43,57,80 Many women internalised and accepted mistreatment as normal,^40,66 while others reported feeling pressured into remaining silent.^40,52

Most women faced discrimination based on their socio-economic status and ethnic background.^{39,45,46,51–53,61,76} There were reports of painful vaginal examinations, no informed consent, confidentiality breaches, neglect, and delays during care.^{45,48,58,59,80} Most women reported a lack of emotional support from their care providers.^43,49,58,76 Many mothers also report verbal abuses.^{51,53,58,59,74,80} Care providers’ favouritism and bias toward wealthier or socially connected clients undermined respectful care to less fortunate women.^39,52,66 Women reported punishment from care providers for improper clothing, not carrying their birthing materials/documents, and late arrival.^62,63

Healthcare providers-identified barriers

Unfavourable attitudes,^{46,51,53,56,61,64–66,78,80,81} limited knowledge,^42,49,50,81 and inadequate skills among staff were self-reported barriers of RMC.^44,49,50 Healthcare professionals were observed using force, including physical restraint, fundal pressure,⁴⁵ and other forms of physical violence during labour.^59,80 Many care providers mistreated women due to frustration, stress, fatigue, and burnout.^{39,41–43,45,46,49,56,75,80} Disrespect toward midwives by some family members and blaming them for adverse birth outcomes hindered their ability to provide respectful care.^39,46 Care providers reported that women’s ‘uncooperative’, ‘disobedient’, and ‘aggressive’ behaviours were barriers to delivering RMC.^{45,46,54,61,72,73}

Individual facilitators

Good understanding, attitudes and motivation

In some settings, improving midwives’ knowledge and practices, and providing ongoing education served as key facilitators of RMC.^59,64 Care providers with favourable attitudes toward RMC were more likely to implement it effectively.^50,55 Strong staff commitment and motivation facilitated improvements in RMC.^41,52,79 Compassion, kindness, and empathy were key provider behaviours that facilitated RMC.^43,44,48,55 Prioritising women’s needs, respecting their privacy, supporting informed choices, and fostering collaborative care all facilitated RMC.^{44,50,55,57,58,60} Using friendly, courteous language and providing abuse-free care were positive factors that enhanced RMC.^{48,55,58,60,67}

Interpersonal barriers

Poor women-provider communication

Inadequate communication skills among care providers^{39,58,59,73,76,77,80} and poor interactions with women hindered the provision of RMC.^{27,28,43,46,54,59,61} Women were often excluded from care decisions,^58,67,76 leading to distrust.^44,50 Language barriers and the lack of available translators further contributed to misunderstandings and increased the risk of mistreatment.^52,53

Weak healthcare team collaboration

Perceived professional hierarchies, with doctors ranked above midwives and nurses, hindered RMC quality.⁴² RMC implementation was also hindered by disorganised management, lack of accountability, and unethical practices.^39,41,60 Poor supervision, ignored staff concerns, and authoritarian management styles exacerbated mistreatment.^{41,46,49,59,66,76}

Interpersonal facilitators

Good interpersonal relationships

Positive care provider/s-woman interactions, trust, and holistic care facilitated RMC implementation.^48,53,60 Effective communication between care providers and women enhanced understanding and cooperation.^48,50,58,62 Encouragement and support of the mother-baby relationship during the immediate postnatal period also facilitated RMC.⁶⁰

Organizational-level barriers

Poor facilities and shortage of resources

Healthcare facilities in low-resource countries often lacked essential medications, consumables, privacy screens, bed linen, infection control supplies, blood packs, and fetal monitoring equipment.^{39,41–43,45,47–50,52,56,58,59,63–67,73–75} Generally the low standard of facility construction, limited space or overcrowding, lack of water and sanitation, as well as inadequate lighting and ventilation were recognised barriers.^{39,42,47,49,50,52,54,57,59,62,66,67,73,77,80} Lengthy procurement processes, low-quality equipment, and inadequate financing⁴² were reported. Low pay, poor incentives, and staff shortages contributed to disrespectful care.^42,48,59

Systemic barriers

RMC was diminished in cultures where disrespect and abuse are normalised, bribery was evident, healthcare costs for patients were high, and family companionship during labour and birth was restricted.^{39,43,46,49,52,54,57,58,76} High workloads and long shifts further hindered RMC.^{39,41,42,46,48–52,54,59,62,64–66,73–77,80} For women, long waiting times, deficient electronic systems/record keeping, transport and referral delays, and limited access to services and specialists, contributed to poor RMC.^{49,50,52,62,64,65,74,80}

Organizational level facilitators

Good institutional norms, support, and practices

Facilitators of RMC included safe, effective, and timely care, as well as high-quality service.^55,60,67 Other facilitators included managerial support, better infrastructure, mentoring, staff development, higher wages, and staff-friendly rostering.^{42,46,55,79,81} Allowing companionship during childbirth was found to significantly enhance RMC implementation.^46,57

Policy level barriers

Lack of guidelines and policies

Policy-related barriers to RMC included poor adherence to existing policies, unclear RMC core principles and indicators, outdated evidence and clinical algorithms, lack of national guidance, and the absence of a designated entity or process for reporting mistreatment.^39,59,61,73 Lack of standardised measurement methods and varying guideline interpretations among care providers further hindered effective implementation.^44,49

Poor education and professional development

In several settings, midwives reported limited access to, and insufficient ongoing professional development and training.^{39,49,61,65,73,75} Other barriers included the omission of RMC from pre-service training, lack of updated evidence-based resources, and weak professional associations.^51,75,76

Policy level facilitators

Capacity building and professional motivation

RMC implementation was strengthened through capacity-building initiatives, including training and health professional education.^{42,57,64,65,75,77,79,81,85,86} Additionally, professional pride in being a midwife was believed to support the provision of respectful care.⁴⁶

Societal-related barriers and facilitators

Socio-cultural related barriers

Societal acceptance of disrespect, intimate partner violence, and civil conflict create environments that limit RMC implementation.^40,76 Unmet societal expectations regarding birth practices and traditional customs can further inhibit RMC.^49,62 Cultural norms that reduce women’s autonomy and social status limit their ability to make decisions about birthplace, mode of birth, and companionship during childbirth.^54,62,63,68

Socio-cultural related facilitators

Health promotion education that empowers women and communities facilitates respectful care.^49,65 Continuous support from companions during childbirth, along with emotional support from family, also enabled RMC in several settings.^57,58,62

Discussion

The Socio-Ecological Model (SEM) provides a structured framework for analysing the barriers and facilitators of RMC across multiple levels.^20,24 In this review, drivers of RMC were identified at the individual, interpersonal, organizational, policy, and socio-cultural levels. The synthesis of these drivers was guided by the Bohren et al. (2015) framework.³⁸ Consistent with the SEM, Bohren et al. (2015) highlighted that poor RMC arises from both individual behaviours and broader systemic factors.³⁸ According to the socio-ecological framework challenges such as inadequate provider knowledge, limited resources and institutional support, and cultural norms cannot be addressed in isolation.^20,38

The application of the SEM in this review enabled a more comprehensive understanding of drivers of RMC that may otherwise have been overlooked. At the individual level, many women in LICs demonstrated limited health literacy and poor awareness of their rights to respectful care.^40,50,54,66 This aligns with a study in Southeast Nigeria, which found that most women have low awareness of their basic human rights and perceive healthcare providers’ disrespectful behaviours as normal.⁸⁷ Such gaps in understanding might stem from broader system-level issues, like inadequate education for women from healthcare about RMC.⁷⁰ SEM emphasises that individual behaviours are shaped by interconnected factors like interpersonal, and institutional factors.²⁰ For example, care providers reluctance to support women was influenced by their perceptions of labouring women as unfriendly, difficult, uncooperative, unappreciative, and aggressive.^88–90 Ige et al. (2022) further noted that women’s negative reactions may partly reflect unmet expectations, indicating the reciprocal dynamic between women and care providers.⁹⁰ Through the SEM lens, these interpersonal tensions can be understood as emerging within organizational and structural environments that offer limited support, foster power imbalances, and fail to prioritise respectful care.⁵

At the intrapersonal level, factors like knowledge, attitudes, skills, and intentions of care providers can influence the provision of care.²⁰ In this review limited knowledge, negative attitudes, and abusive practices among maternity care providers impeded RMC delivery in low-income countries.⁹¹ This may be due to the lack of RMC in pre-service training or undergraduate education and ongoing training.⁸⁷ Midwives working in LICs often reported feelings of underappreciation, and frustration, which may contribute to displaced aggression.^72,89 Similarly, studies from Nigeria and Guinea found that poor compensation and lack of recognition hindered RMC provision.^72,87 These insights show that when systems fail to protect women’s rights and prioritise respectful care, both women and midwives experience heightened frustration and a sense of powerlessness.²⁸

In this review, the SEM indicated that interactions between women and providers, and within care teams, were shaped not only by interpersonal dynamics but also by organizational, policy and sociocultural factors.^20,88 System level barriers such as high workloads, understaffing and a culture of disrespect further shaped how providers and women engaged with each other, demonstrating the cross-level influences central to the SEM.^72,87 Evidence from two Brazilian public hospitals aligns with our results, indicating that poor communication by providers was a key barrier to RMC.⁹² Lambert et al. (2018) also found that miscommunication between women and providers were a major challenge to delivering quality care.⁹³ Conversely, increased interaction between women and healthcare providers,⁴ and strong inter-professional collaboration facilitated a continuum of care that supported optimal maternal and neonatal outcomes.⁹⁴

By applying SEM, institutional level factors such as resource shortages, inadequate infrastructure and poor accountability mechanisms can be interpreted as central structural determinants of RMC rather than isolated operational issues.²⁷ These findings align with evidence from Nigeria, which identified poor work environments, including inadequate space, stressful hospital protocols, and lack of equipment were significant obstacles to RMC.⁸⁷ In Sub-Saharan Africa structural inequalities, health system policies, and hierarchical work environments negatively influenced staff practices.⁸⁸ Another study indicated that mistreatment during childbirth was associated with weak redress mechanisms.⁸⁷ According to SEM organizational constraints can ripple downward, influencing relationships at the interpersonal level as well as providers’ behaviours and women’s experiences at the intrapersonal level.²⁰ Findings supported the SEM notion that institutional systems created the conditions in which respectful or disrespectful care became normalised.²⁸

At the policy level, national guidelines, measurement tools and professional training shape the broader context in which maternity facilities operate.^38,59,95 Weak enforcement of RMC standards and outdated guidance undermine organisational capacity and create norms that enable mistreatment.³⁸ Strengthening midwifery education is crucial, as standardised training improves maternal and newborn outcomes and enhances women’s care experiences.⁹⁶ WHO recommends that all women and newborns receive care from fully trained and authorised midwives.⁹⁶ Countries such as Ethiopia, Burkina Faso, Cambodia, Indonesia, and Morocco have strengthened their midwifery education and reduced maternal mortality.⁹⁷ Viewed through the SEM lens, these findings indicate that policy-level factors influence education, resource availability, provider working conditions, and women’s awareness of their rights.²⁰ This highlights that improving RMC requires comprehensive policy reforms, updated guidelines, high-quality midwifery education, and supportive professional environments.⁵

Though majority of the studies included in this review are from Ethiopia and Tanzania, the barriers and facilitators identified are mainly distributed across the least-developed countries. Evidence from WHO guidelines indicated that normalisation of disrespect and abuse, fragile health system, patriarchy, health literacy are identified as the main causes of mistreatment.⁴ This normalisation culture of disrespect and abuse in low-income countries is mainly due to power-imbalance between women and care providers, which may contribute to unprofessional behaviour and low morale.³⁸ In line with these findings, according to Foucault’s theory, power imbalances and the medical gaze can undermine the relationship between health care providers and consumers, thereby exacerbating experiences of disrespect and abuse.⁹⁸

Through the application of SEM in this review, we can also understand that community norms, beliefs, and collective expectations form a social environment that shapes both women’s expectations and providers’ behaviour. Our findings identified community-level factors affecting RMC such as stigma, acceptance of disrespect and abuse, cultural expectations around childbirth, domestic violence, societal hierarchies, and gender discrepancies.^62,63,68,76 Similarly another study identified barriers of RMC included limited women autonomy and empowerment, as well as the normalisation of mistreatment of women in society.⁸⁷ Interpreting these through SEM showed that socio-cultural norms operate as a bridge between structural conditions and individual experiences, reinforcing or challenging facility practices.⁹⁹ Thus, sociocultural drivers identified through SEM help clarify why even well trained providers may operate within culturally embedded patterns of care.²⁷

This review identified several facilitators of RMC. The primary facilitators identified include improving healthcare providers’ competency regarding RMC and implementing midwife-led continuity of maternity care. Healthcare providers’ understanding of RMC can be improved by educating them on the core principles of RMC.⁶ This education includes providing women with clear information, supporting informed decisions, maintaining privacy, ensuring safety, delivering abuse-free care, and ensuring continuity of care with a familiar caregiver throughout perinatal period.⁶ These core principles strengthen the midwife-led continuity of maternity care model, which prioritises women-centred care.

Midwifery-led continuity of care had a significant positive impact on maternal and neonatal health.¹⁰⁰ Evidences from low and middle income countries support expansion of midwife-led care models, which enhance respectful interactions, reduce unnecessary interventions, and improve birth experiences.¹⁰¹ Although the effectiveness of Midwifery-led continuity of care in resource-limited settings is well-documented, evidence concerning its feasibility in under-resourced settings remains fragmented.¹⁰² Healthcare systems should invest in midwife-led continuity of care, offer education about respectful care, and establish environments that allow midwives to practice to their full scope while prioritising women’s needs.¹⁰³

Limitations

This review used a rigorous method for gathering evidence, synthesising data, and organising findings. This is the first systematic review to explore barriers and facilitators of RMC in low-income countries. Although we implemented thorough searching strategies in five databases and reviewed the reference lists of systematic and other literature reviews, we may have missed some critical studies. As only studies published in English language were included, this review may have missed relevant studies published in other languages. Despite a comprehensive search across all low-income countries, no eligible studies were identified from Angola, Bangladesh, Benin, Bhutan, Burkina Faso, Burundi, Cambodia, Central African Republic, Chad, Djibouti, Eritrea, Gambia, Guinea, Haiti, Micronesia, Kiribati, Lao Peoples Democratic Republic, Lesotho, Liberia, Mali, Mauritania, Niger, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Timor-Leste, Togo, Yemen, Comoros, Democratic Republic of the Congo, Sudan, and Tuvalu. Consequently, insights from these countries are lacking, highlighting a significant gap in up-to-date evidence and the need for further research. Because most studies focused on facility-based experiences, there was limited insight from research on community-based births. Furthermore, the lack of a meta-analysis, together with the limited number of studies in certain categories, restricted the generalisability and interpretability of findings.

Conclusions

This review presented a synthesis of barriers and facilitators of RMC at the individual, interpersonal, organizational, policy, and socio-cultural levels using the SEM as a framework. This review found that barriers and facilitators to RMC were not only women-related but also influenced by healthcare provider behaviours, experiences in the workplace and society in which women lives and births. The main barriers identified were care providers’ limited knowledge, inadequate skills, and abusive behaviours. To improve providers’ proficiency in RMC, we recommend implementation of RMC core principles, particularly tailored to the context of low-income countries.⁶ These principles include providing care that is free from abuse, attentive, informed consent, autonomous, confidential, equitable, safe, respectfully communicated, culturally sensitive, and offered in optimal birth setting.⁶ These core principles were validated based on WHO quality of maternity care standards.³⁸

Administrators, policymakers, and healthcare facilities should consider the identified barriers and facilitators when planning further interventions. Higher education institutions should integrate RMC into pre-service educational programs related to maternity care. Healthcare institutions should ensure that maternity care providers receive updated education on RMC while on duty.

Supplemental material

Supplemental material - Overcoming barriers and harnessing facilitators: Respectful maternity care in least-developed countries - a systematic review

Supplemental material for Overcoming barriers and harnessing facilitators: Respectful maternity care in least-developed countries - a systematic review by Ephrem Yohannes, Gonfa Moti, Eshetu E. Chaka, Laura Gabriel, Debra K. Creedy, Carolyn Hastie in Women's Health

Supplemental material

Supplemental material - Overcoming barriers and harnessing facilitators: Respectful maternity care in least-developed countries - a systematic review

Supplemental material

Supplemental material - Overcoming barriers and harnessing facilitators: Respectful maternity care in least-developed countries - a systematic review

Supplemental material

Supplemental material - Overcoming barriers and harnessing facilitators: Respectful maternity care in least-developed countries - a systematic review

Footnotes

Acknowledgements

We extend our sincere gratitude to Ambo University and Griffith University School of Nursing and Midwifery for their generous permission to conduct this study.

ORCID iDs

Ephrem Yohannes

Gonfa Moti

Eshetu E. Chaka

Laura Gabriel

Debra K. Creedy

Carolyn Hastie

Ethical considerations

This study is a systematic review of publicly available studies, and ethical approval was not required.

Authors’ contributions

EY was actively involved in the study’s design, drafting and conceptualisation. EY and GM engaged in article selection, data extraction, interpretation and analysis. CH, DC, LG, EE, and GM provided substantial feedback and contributed meaningfully to the refinement of the manuscript. All authors contributed to the critical revision and editing of the manuscript’s intellectual content. All authors have read and approved the final version of the manuscript. All authors agreed to be accountable for all aspects of the work, ensuring that any questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All relevant data to the review are included in the paper or uploaded as an additional file.*

Supplemental material

Supplemental material for this article is available online.

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