A cross-sectional study on the prevalence of respectful maternal care among postnatal women during facility-based childbirth in a tertiary care centre in Bihar, India

INTRODUCTION

Maternal health encompasses the well-being of women during pregnancy, childbirth, and the postnatal period. Each of these stages should be a safe and positive experience for both the mother and baby. Although significant improvements have been made in the last two decades, an estimated 287,000 women died globally due to pregnancy and childbirth-related causes in 2020, according to the WHO.¹ Most of the maternal deaths, including those reported globally, are preventable if they are performed by a skilled health care provider on time in a supportive environment.

According to the WHO, respectful maternity care (RMC) refers to the humane and dignified treatment of a childbearing woman throughout her pregnancy, childbirth, and the postpartum period. It focuses on women’s rights and preferences through effective communication and positive attitudes.² The concept of safe motherhood initiatives is a global effort, and it is designed to reduce maternal death and improve women’s health through social, community, and economic interventions. This should include rights to maintain dignity and respect, ensuring appropriate supportive care, and autonomy for pregnant women during maternity care.³ However, reported evidence indicates that disrespect and mistreatment during childbirth remain prevalent globally, including physical or verbal abuse, discrimination, and non-consented care.^2,4 Globally, disrespect and abuse during labour have been widespread, ranging from 15% in Tanzania to over 90% in Nigeria and Peru.^5-7 The study by WHO (2019) in four lower-income countries- Ghana, Guinea, Myanmar, and Nigeria- showed that 42% of women experienced abuse or neglect during the childbirth process.⁸

In India, the Ministry of Health and Family Welfare, Government of India, also launched a program, Laqshya (Labour Room Quality Improvement Initiative), in 2017 to enhance beneficiary satisfaction, promote positive birthing experiences, and provide RMC to all women accessing public health services.⁹ However, disrespect and abuse during childbirth have also been documented in various parts of India. For instance, disrespect in intrapartum care within community health facilities was highlighted in Gujrat.¹⁰ A study in West Bengal found that 37.6% of women experienced at least one form of disrespect or abuse during facility-based childbirth, while 98.5% of women experienced the same in Uttar Pradesh.^11,12

Women are particularly vulnerable during pregnancy, labour, and childbirth, and inadequate maternity care has been linked globally to adverse physical and psychological outcomes. Evidence from the UK indicates that insufficient care leads to breastfeeding reluctance and poor mother-infant bonding.¹³ A qualitative study from Denmark documented unsatisfactory sexual relationships, and findings from Iran reported reduced quality of life.^14,15 Also, lack of supportive care during childbirth is associated with increased fear of vaginal delivery, reluctance to use alternative birthing positions, and greater preference for caesarean section.^16-18 Although these traumatic experiences may decrease over time, they can persist in memory up to five years.¹⁹ A prospective cohort study of Iranian women showed a direct correlation between RMC and a positive birthing experience.²⁰ Therefore, maternity staff have a great role in the physical and emotional aspects of pregnancy, can provide compassionate and supportive care throughout the pregnancy.

In India, RMC studies are not explored much; particularly, they remain scarce in the eastern region. Bihar is a low socio-economic state in eastern India with a population of 10.41 crore and reports that 64% of births occur in health facilities (NFHS-4, 2015-16).²¹ A qualitative study has explored in Bihar related to women’s childbirth using body mapping techniques, however, a comprehensive assessment of RMC is not documented in the literature.²²

Therefore, this study aimed to determine the prevalence of RMC during facility-based childbirth in a tertiary care hospital of Bihar and to analyse its association with maternal background characteristics.

METHODS

Study design

It was a cross-sectional descriptive research design was adopted for this study.

Operational definition

Prevalence

Prevalence is calculated as the number of postnatal women who received adequate respectful maternity care divided by the total number of postnatal women in the study, multiplied by 100.

RMC

RMC is measured using the PCMC-India scale. Women scoring equal to or above the mean score of the full PCMC scale and each subdomain are categorized as receiving adequate RMC, while those scoring below the respective mean are considered as receiving inadequate RMC.

Postnatal women

Refers to all mothers who have undergone childbirth (vaginal or cesarean) and have been admitted to the postnatal ward of All India Institute of Medical Sciences (AIIMS) Patna during the data collection period. Among them who are available, willing to participate, and able to provide coherent responses are included.

Study setting

This study was conducted in the postnatal ward of the AIIMS, Patna, Bihar. Patna, the state capital with a population of about 2.35 million, covering an area of approximately 250 square kilometres, is a key urban centre in eastern India. AIIMS Patna is a government tertiary care teaching and research hospital that serves as a referral centre for the diverse population of Bihar and nearby states. It provides comprehensive maternal and child health services along with other major departmental services, conducts 150-200 deliveries per month (1,800-2,400 annually) through vaginal or caesarean section. The hospital is well-equipped and adequately staffed with multidisciplinary teams to manage its high patient load.

Study period

This study took place for a period of 2 months from mid-January to mid-March 2025.

Study population

Postnatal women who have delivered in AIIMS Patna during the study period.

Inclusion criteria

Postnatal mothers, defined in the above section, were included with their written consent.

Exclusion criteria

Postnatal mothers who were unavailable during the study period or had delivered in hospitals other than AIIMS Patna.

Sampling technique

A convenience sampling technique was used.

Sample size

Poudel et al conducted a study on RMC in Nepal. Results showed that only 17% of women had received RMC.²³ So, from there prevalence rate was taken as 17%.

n = sample size

d=5%, that is the confidence interval (then d =0.05)

p=Expected prevalence or proportion (17%) =0.17 (Expected prevalence of RMC among postnatal women during facility-based childbirth)

Where, q = (1-p) = (1- 0.17) = 0.83

Z_α= 1.96 at 95% CI

So, by putting the values in the formula,

n= 216.82=217

Therefore, the calculated sample size was 217. As data were collected at a single point in the health facility before discharge, there was no follow-up component; therefore, dropout rates were not considered in this study.

Study variables

Research variable

Prevalence of RMC among postnatal women during institutional delivery.

Background information

Socio-demographic variables- age, residence, religion, education, occupation, and monthly family income.

Obstetric variables- parity, antenatal care (ANC) follow-up, gestational age, mode of delivery, and outcome of present pregnancy.

Data collection tools:

Tool-I was a semi-structured questionnaire, developed from the literature review and experts’ opinion, to collect socio-demographic and obstetric data. These variables were included as they influence healthcare access, decision-making, and women’s perception of RMC.

Tool-II standardized PCMC scale- India, developed by Afulani et al, to evaluate the prevalence of RMC.²⁴ Prior permission was obtained from the author for the use of this tool. This tool has demonstrated good content, construct, and criterion validity, and shows high internal consistency (Cronbach’s alpha =0.85). The tool is divided into three conceptual domains, namely communication and autonomy (9 items), dignity and respect (6 items), and supportive care (12 items). Subscales for dignity and respect, communication and autonomy, and supportive care are also demonstrated acceptable reliability (Cronbach’s alpha range: 0.67-0.73). The PCMC scale has 27 items with a total score from 0 to 81, and higher values depict more positive experiences of maternity care.

Technique

A face-to-face interview schedule was conducted to collect the data.

Ethical approval

The ethical approval for this study was obtained from the Institutional Ethical and Research Committee, AIIMS Patna (Ref. No.: AIIMS/Pat/IEC/1375, dated 30.12.2024). Written informed consent was obtained from all participants after explaining the aims and objectives of the study, as well as their right to withdraw at any stage without affecting their care. Confidentiality and anonymity were strictly maintained throughout the study.

Data collection process

This prospective study was conducted over two months (mid-January 2025 to mid-March 2025) in the postnatal ward of AIIMS Patna. Eligible women were identified according to defined above inclusion and exclusion criteria during daily ward rounds, excluding Sundays and public holidays. Clinical details were verified from medical records. A trained investigator introduced herself, explained the study’s aims, objectives, risks, and benefits in the local language (Hindi), and obtained written informed consent. Ethical approval was secured from the institutional ethics committee before data collection. Bedside interviews were conducted before discharge from the hospital, ensuring privacy, confidentiality, and minimizing disturbances from staff and family members. During the study period, a total number of 318 women were admitted to the postnatal ward. Of 225 approached, 219 consented, and complete data were obtained from 215 participants; four incomplete responses were excluded. Reasons for non-participation included reluctance to discuss childbirth, postpartum fatigue, maternal or neonatal illness, or non-specific responses. A total of 312 deliveries occurred, including 141 vaginal and 171 caesarean births, with 301 live births and 11 stillbirths/IUFDs during the study period.

Statistical method

Collected data were entered in Microsoft Excel and analysed using SPSS version 25.0. Women’s experiences of RMC were assessed using a 4-point Likert scale (03: no, never =0; yes, a few times =1; yes, most of the time =2; yes, all the time =3). Negatively framed items were reverse-scored. Total scores ranged from 0-81, with higher scores indicating better care; these were rescaled to 0-100 for domain-wise comparison using the formula:

Categorical variables, i.e., socio-demographic and obstetric variables and PCMC categories, were summarized as frequencies and percentages using descriptive statistics. Quantitative variables (age, PCMC scores) were tested for normality by checking skewness, kurtosis, the Shapiro-Wilk test, histogram, and Q-Q plot. Our data showed a normal distribution. So, the mean and standard deviation (SD) were reported.

Based on the PCMC scale score guidelines, the mean value was considered the cut-off for RMC, which is also followed by several groups.^11,24-32 Women scoring equal to or above the mean score were categorized as receiving adequate RMC for most of the time, while those scoring below this threshold, considered to have an inadequate RMC. Chi-square tests were used to examine associations between RMC prevalence and selected sociodemographic and obstetric variables. A two-sided p value <0.05 was considered statistically significant at a 95% confidence interval.

RESULTS

Frequency and percentage distributions of background information are depicted in Table 2. Among the socio-demographic variables, the majority of women (75.3%) were aged between 21 and 30 years, with a mean age of 26.3 years (±SD 4.51; range 17-42). Over half of the participants resided in rural areas (52.6%), and most identified as Hindu (81.4%). The majority had completed education up to the intermediate level (grades 11-12) and were primipara (61.4%).

Table 3 shows the percentage distribution of the women’s responses to the PCMC items by their subdomain. In the dignity and respect subdomain, the majority of women (66%) were treated with respect by healthcare providers at all times. While 61.4% of women were always treated in a friendly manner, 23.3% reported verbal abuse (12.6% once, 9.3% a few times, 1.4% many times). Physical abuse was reported by 1.9% (1.4% once, 0.5% a few times). More than half of the women (53%) experienced being always covered with a blanket or screen to maintain privacy during examinations in the labour room.

In the communication and autonomy subdomain, 36.7% of participants explained that healthcare providers never introduced themselves when they first interacted with them. However, more than three-fourths of women (77.2%) said they were always called by name and actively involved in their care. The maximum of the women (81.4%) said that consent or permission was taken all the time before doing any procedure or physical examinations, and 66.5% were given explanations all the time before undergoing procedures. In the supportive care subdomain, the majority (78.1%) of women received the treatment in a delay (just a little long: 40.9%, somewhat long: 29.3% and very long: 7.9% Also,78.6% of them had no birth companion present during delivery. Despite all these, 61.9% of women experienced that healthcare providers always gave them attention when needed and delivered the best possible care. Overall, 14.4% of participants described that the facility environment was not satisfactory, including 8.8% dirty and 5.6% very dirty.

*Negatively framed question.

**The raw scores of the PCMC scale and its subdomains were rescaled to a 0-100 scale.

PCMC scale and subdomain scores were rescaled to 100 for comparison. The overall mean score was 76.25 (SD=11.69; range 30.86-100). Mean scores of the PCMC scale and each subdomain are presented in Table 4. The dignity and respect subdomain had the highest mean score (81.80) among the three PCMC subdomains. To measure prevalence, participants with a rescaled score more than or equal to the mean (≥76.25%) in the full PCMC scale were considered to have received adequate RMC most of the time, while scores below 76.25% indicated inadequate RMC, reflecting some form of disrespect or abuse. The prevalence of RMC and its subdomains is shown in Figure 1, which indicates that overall, 54% of women received adequate, respectful maternal care during their stay in the facility. Similarly, the prevalence of each subdomain was calculated using its respective mean value, in which 57.2% of participants received adequate care in the dignity and respect domain and 53% in the supportive care domain. In Table 5, the association between RMC and background information was analyzed using the Chi-square test. Among the socio-demographic variables, only religion showed a statistically significant association with RMC (level of significance p<0.05, degree of freedom, df=1) with a 95% confidence interval. No significant associations were found between any of the obstetric variables and RMC.

*P<0.05. Women with scores equal to or above the mean of the rescaled full PCMC score were categorised as having received adequate RMC, while those with scores below the mean were considered to have received inadequate RMC.

Women scoring equal to or above the mean score of the rescaled full PCMC score and its subdomain were categorized as receiving adequate RMC, while those scoring below the respective mean were considered as receiving inadequate RMC.

DISCUSSION

Safe, respectful, and good-quality maternal health care services play a key role in reducing maternal morbidity and mortality globally. Facility-based childbirth has increased in India due to government incentives and programs. However, current research highlights concerning experiences reported by women during pregnancy, especially during childbirth. This study found that only 54% of participants received adequate RMC during their stay at the health settings, indicating that nearly half of the women (46%) did not experience optimal care. These values also vary for different regions of India, which are socio-economically distinct, in the range of 16.3% in the northern region to 73.7% in the central region may be due to differences in study settings and influencing factors.^11,33,34 A systematic review in India also reported prevalence rates of disrespect ranging from 20.9% to 100% 35. Evidence is also similar for the economically weak countries like Pakistan, Kenya, and Ghana, using the same PCMC scale.^25,27 Globally, the prevalence of disrespect and abuse during childbirth varies widely, from 15% to 98%.^20,36-38 The mean PCMC score varies widely in different studies globally.^27-32 A global review reported the mean scores of 75 in Africa, 60-90 in Asia, and above 80 in North America, with the lowest score of 38.2/100 in Sierra Leone.²⁶ For rural India, this score is 60% which is close to our study (76.25%) conducted in urban areas.³⁴ In all these cases, Communication and autonomy consistently emerged as the lowest-scoring domain; for example, Ethiopia reports just 18.1/100 in comparison to our study findings of 11.11/100.²⁶ The highest prevalence of adequate RMC occurred in the dignity and respect subdomain, followed by the supportive care domain. This scenario is also observed in different studies inside India, based on different states, indicating good compassion towards pregnant women.³³ Also, it shows the highest value for the global studies.^27,28,31,39 The abuse was in the form of physical (pushed, beaten, slapped, pinched, physically restrained, or gagged) and verbal (shouted, scolded, insulted, threatened, or talked rudely). In our case, 23.3% of women reported verbal abuse and 1.9% reported physical abuse, which is lower than findings from Colombo, Sri Lanka (28.5% verbal, 14.8% physical)and Pakistan (36% physical, 22% verbal).^27,29 In this context, Ethiopia and Kenya showed a lower percentage compared to India.^28-31 In the communication and autonomy subdomain, lack of a health care provider’s introduction upon first contact, consent, and explanation before examination or procedure contributed substantially to lower RMC scores. In the supportive care domain, a delay in receiving treatment, not permitted birth companions during delivery, absence of emotional support, and poor facility environments are key contributors to inadequate RMC in India and similar settings globally.^{27,28,30,31,33,40}

This study found a statistically significant association between religion and RMC, with a Pearson Chi-square value of 0.008 at 1 degree of freedom and a 95% confidence interval (p<0.05). Another study from India also reported a similar association, reflecting the influence of religious diversity on experiences of disrespect.⁴⁰ In contrast, this association was not significant in a less diverse context, such as Pakistan.²⁷ This association needs to be studied in more detail in diverse religious countries like India and other continents.⁴¹ A study from Ethiopia reported significant associations between RMC and factors such as maternal age, occupation, and antenatal follow-up.⁴² However, our findings showed no significant association between RMC and other socio-demographic or obstetric variables.

This study’s strength includes the use of a validated PCMC-India scale, interviews conducted before discharge from the hospital to minimize recall bias, and a single trained, independent investigator with a structured tool, strengthening data quality. Conducted in a tertiary care centre of a region with a lack of research on RMC, adds another important contextual evidence. However, limitations include possible underreporting of data due to fear of disclosing mistreatment in the hospital setting, poor response due to fatigue and tiredness in the early postnatal period, a single-centre study, and a small sample size for generalization of study findings. Another limitation of this study is that it was conducted in a tertiary care hospital, which handles complicated deliveries and referrals, so the findings may not reflect lower-level facilities and could have influenced women’s experiences, and this should be explored in future studies.

CONCLUSION

The study found that the prevalence of respectful maternal care (RMC) was 54%. Among the subdomains of RMC, the most lacking area was communication and autonomy, followed by supportive care. Although the incidence of abuse was relatively low, there was a gap in positive interactions between healthcare providers and patients. Key issues included a lack of privacy during examinations, limited choices in birthing positions, the absence of preferred companions during delivery, and long waiting times for treatment. These shortcomings highlight significant gaps in the healthcare delivery system and call for training maternity staff, especially in good communication skills, promoting birth companionship, and providing supportive care. Positive childbirth experiences can increase the use of public maternal healthcare services. Therefore, more research is needed to explore factors associated with poor patient-provider interactions in healthcare settings to enhance RMC and encourage women to give birth in facilities.

ACKNOWLEDGEMENTS

Authors thank Dr. Ashok Kumar for his valuable input on the statistical analysis. We also express our gratitude to the participants for their active involvement in this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee Ref. no AIIMS/Pat/IEC/1375 dated 30.12.2024

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