Strengthening Respectful Maternal and Newborn Care: Advancing Measurement and Implementation Science Across Contexts

Abstract

Respectful maternal and newborn care is an essential component of high-quality health services, yet women across diverse settings continue to report mistreatment, poor communication, and unmet expectations during childbirth. These concerns are especially pronounced in fragile and humanitarian contexts, where health system constraints can undermine both clinical quality and women’s experiences. Despite growing global emphasis on respectful care, validated measures that capture key aspects of women’s experiences remain limited, and little implementation science evidence exists for how respectful care can be operationalized globally, particularly in Middle Eastern health systems. This dissertation addresses these gaps through three studies: development and validation of mistreatment measures in the occupied Palestinian territory (oPt), validation of a multidimensional satisfaction with childbirth care scale using multi-country data from a World Health Organisation (WHO) study, and a qualitative study exploring health worker perspectives on implementing a labor companionship intervention in three Middle Eastern hospitals. The first study developed concise, domain-specific mistreatment scales using Item Response Theory (IRT) applied to survey data from 745 postpartum women in the occupied Palestinian territory (oPt). For each domain, a full item set (all items) and a brief item set (reduced subset) was evaluated to determine whether shorter item sets retained comparable psychometric properties. Physical abuse and stigma items were excluded as a result of less than 1% responses, while domains related to poor rapport, failure in professional standards of care, and health system conditions and constraints showed strong item discrimination and adequate model fit. Each of these domains produced a brief scale consisting of 3 to 4 mistreatment items, retaining strong psychometric performance. The brief scales performed comparably to the full item set of the community survey, and importantly, odds ratios for associations with dissatisfaction with care were similar for both full and brief scales. For example, poor rapport was associated with 2.8 times higher odds of dissatisfaction using the full item set and 2.7 times higher odds using the brief item set. Failures in professional standards demonstrated a similar pattern, with odds ratios of 2.3 for the full item set and 2.2 for the brief item set. These consistent effect sizes support the feasibility of integrating short, validated mistreatment measures into routine monitoring and accountability systems in constrained settings. The second study validated a satisfaction with childbirth scale using data from 2,672 postpartum women in Ghana, Guinea, Nigeria, and Myanmar. Exploratory and Confirmatory Factor Analyses confirmed a two-factor structure representing Interpersonal Satisfaction and Structural Satisfaction, with Cronbach’s alpha values of 0.82 and 0.71 respectively. Mistreatment exposures were strongly associated with dissatisfaction across both domains. Women who experienced any mistreatment had 1.5 times higher odds of structural dissatisfaction and 2.8 times higher odds of interpersonal dissatisfaction. Specific forms of women-reported mistreatment demonstrated notable associations with the satisfaction scales. Physical abuse increased the odds of dissatisfaction by 1.5 times for structural and 1.9 times for interpersonal experience. Verbal abuse increased the odds by 1.5 and 2.9 respectively. Denial of companionship produced odds ratios of 2.1 for structural dissatisfaction and 3.1 for interpersonal dissatisfaction. Women reporting lack of health worker responsiveness to their needs showed the strongest association, with 11.1 times higher odds of interpersonal dissatisfaction. These patterns provide strong criterion validity and demonstrate that the validated satisfaction scale can meaningfully differentiate women’s experiences across diverse health systems. The third study examined health worker perceptions of implementing a labor companionship model in tertiary hospitals in Egypt, Lebanon, and Syria using qualitative methods guided by the Consolidated Framework for Implementation Research (CFIR). This framework informed exploration of how individual, inner setting, outer setting, and process-level determinants shaped health worker experiences. Health workers described indicated that heavy workloads, overcrowded labor wards, limited staffing, and inconsistent facility policies were major barriers to providing respectful, person-centered care. Despite these challenges, health workers consistently recognized the value of labor companionship for improving communication, reducing anxiety, and enhancing women’s emotional support. Health workers emphasized the need for clearer guidance on lab, supportive supervision, adequate staffing, and training. These findings show that implementing respectful care is shaped by both individual motivation and structural conditions highlighting the importance of the multi-level strategies required for sustainable implementation in complex health system environments. Taken together, the three studies in this dissertation advance the measurement and implementation of respectful maternal and newborn care across diverse settings. The validated mistreatment and satisfaction scales provide robust, context-sensitive tools for monitoring women’s experiences, while the implementation findings identify actionable strategies to strengthen provider behavior, institutional accountability, and feasibility of implementing respectful care interventions. This body of work offers an integrated, evidence-based framework for promoting dignity, equity, and person-centered maternity care across contexts.