Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture To Improve Equitable Maternal Healthcare Delivery and Outcomes
Authors: Cantor Amy G. , Jungbauer Rebecca M. , Skelly Andrea C. , Hart Erica L. , Jorda Katherine , Davis-O'Reilly Cynthia , Caughey Aaron B. , Tilden Ellen L. 
Published: January 2024

Objective. To summarize current research defining and measuring respectful maternity care (RMC) and evaluate the effectiveness of RMC and implementation strategies to improve health outcomes, particularly for populations at risk for health disparities. Data sources. Ovid MEDLINE®, Embase®, and Cochrane CENTRAL from inception to November 2022 and SocINDEX to July 2023; manual review of reference lists and responses to a Federal Register Notice. Review methods. Dual review of eligible abstracts and full-text articles using predefined criteria. Data abstraction and quality assessment dual reviewed using established methods. Systematic evaluation of psychometric studies of RMC tools using adapted criteria. Meta-analysis not conducted due to heterogeneity of studies and limited data. Results. Searches identified 4,043 unique records. Thirty-seven studies were included across all questions, including the Contextual Question (CQ). Twenty-four validation studies (3 observational studies, 21 cross-sectional studies) evaluated 12 tools for measuring RMC. One randomized controlled trial (RCT) evaluated RMC effectiveness. There were no effectiveness trials from settings relevant to clinical practice in the United States and no studies evaluating effectiveness of RMC implementation. For the CQ, 12 studies defined 12 RMC frameworks. Two types of frameworks defined RMC: (1) Disrespect and Abuse (D&A) and (2) Rights-Based. Components of D&A frameworks served as indicators for recognizing mistreatment during childbirth, while Rights-Based frameworks incorporated aspects of reproductive justice, human rights, and anti-racism. Overlapping themes from RMC frameworks included: freedom from abuse, consent, privacy, dignity, communication, safety, and justice. Tools that measured RMC performed well based on psychometric measures, but no single tool stood out as the best measure of RMC. The intrapartum version of the Mother’s Autonomy in Decision-Making (MADM), Mothers On Respect index (MORi), and the Childbirth Options, Information, and Person-Centered Explanation (CHOICES) index for measuring RMC demonstrated good overall validity based on analysis of psychometric properties and were applicable to U.S. populations. The Revised Childbirth Experience Questionnaire (CEQ-2) demonstrated good overall validity for measuring childbirth experiences and included RMC components. One fair-quality RCT from Iran demonstrated lower rates of postpartum depression at 6-8 weeks for those who received RMC compared with controls (20% [11/55] vs. 50% [27/54], p=0.001), measured by the Edinburgh Postpartum Depression Scale. No studies evaluated any other health outcomes or measured the effectiveness of RMC implementation strategies. Conclusions. RMC frameworks with overlapping components, themes, and definitions were well described in the literature, but consensus around one operational definition is needed. Validated tools to measure RMC performed well based on psychometric measures but have been subject to limited evaluation. A reliable metric informed by a standard definition could lead to further evaluation and implementation in U.S. settings. Evidence is currently lacking on the effectiveness of strategies to implement RMC to improve any maternal or infant health outcome.