Theme 1: empathic healthcare provider–woman interactions

Initial interactions between healthcare providers and women on admission to facilities were identified as a crucial first step in establishing a mutually respectful relationship. Participants identified three central components: friendly welcome and courteous language, well-timed appropriate care and information sharing.

A friendly welcome and courteous language

Lay and healthcare provider participants from almost all study sites described the importance of how the woman and her relatives/companions were received at the health facility. Women and family members recalled positive experiences as being made to feel welcome and non-judgmental attitudes by healthcare providers. Likewise, the healthcare providers recognised that receiving women in a ‘proper way’ involving greeting and introducing themselves by name on first contact was important. Using the woman’s name and avoiding overfamiliar or patronising terms was valued. Participants also highlighted how women were spoken to was important, using a calm tone of voice and not shouting.

Honestly speaking, when I arrived at the reception, I was well received, they (nurses) gave me bed to rest on as I was waiting to give birth. When I was about to give birth, they took me to a delivery room, the nurses took good care of me and I delivered safely (Woman—Tanzania).

My daughter was welcomed well, and she did not go through any type of abuse till she was discharged. She was not abused at all and we were discharged properly (Family member—Malawi).

Provider’s education, experience and motivation were all recognised as important facilitators of respectful communication. Lay participants believed that healthcare providers needed not only good preparation including training but also effective role models in practice to develop skills to communicate respectfully.

What made them (healthcare providers) give me that type of care is because of the way the nurses were trained, because the care I received here is the same care I received at the nursery, it means that is how they were taught to do (Woman—Malawi).

Timely and appropriate care

Woman and family member participants identified prompt review, appropriate assessments and interventions meeting the woman’s needs as integral to respectful approach. Women participants particularly valued the prompt initiation of care on arrival at the facility.

There was a doctor coming on time and informing me that you will continue with this and that even the medicine I have to receive (Woman—Tanzania).

Information sharing

Both healthcare providers and lay participants believed that provision of understandable information, was crucial to allow women to participate effectively in decision-making about their care and whether to accept interventions. Women participants appreciated detailed information provided to them and the freedom to agree or refuse interventions.

…they did not force me to close the uterus (tubal ligation), when they have prepared me they took me to the surgery room, they asked whether I was ready to close the uterus, they told me if I was ready to close the uterus, they would help……. I told them that I am ready, and when my husband came, they also asked him, he agreed, and we signed and agreed with nurses (Woman—Tanzania).

Being informed of findings immediately after assessments and giving time to ask questions allowed women to feel empowered in their choices. Healthcare providers also recognised the value of providing women with clear explanations and actively involving them in decisions surrounding care, to protect their autonomy.

When assessing them, we tell them I am doing this because of a, b, c, d and then when we are giving them their treatment, we also explain to them why we are giving them that type of treatment. And we also give them a chance to refuse or accept the treatment. So, they have right to choose, to say I like this position, without shouting at them we give them the freedom to do that (Nurse—midwife—Malawi).

Alongside preservice education, providers recognised that clinical leadership and continuous professional development were important influences for improving and sustaining performance.

We do have a consultant midwife; this consultant midwife always provides in-service trainings like the continuous professional developments each and every week to make sure that we are giving these women the best care (Nurse—Midwife—Malawi).

Although participants focused on examples of positive contacts, several recounted negative experiences, either personal or anecdotal. Opportunities were identified to improve consistency and equity in care provision, through better communication and sharing of information that might require action by facilities and providers.

……the nurse (Midwife) should inform the patient that ‘we want to examine you’ respectfully, not shouting at her at all, so she has to listen, rather than surprising her that ‘hey stretch your hand I want to examine you’ ………. (Family member—Malawi).

Participants suggested more in-service training and improved status for healthcare providers could enhance respectful care.

Training them should be frequent. Also, salary should be increased to them so that they can provide service at their best (Woman—Tanzania).

Theme 2: enabling environment

Participants across both Malawi and Tanzania recognised recent improvements in the facility environments, which had increased privacy and improved care for women. Maintaining privacy was consistently identified as of key importance by women; for example, being covered during physical examinations and protecting confidentiality. Healthcare providers using screens and curtains to protect women during physical examinations were important aspects of this.

…actually they didn't leave my body exposed before the mass [other people], they put screens to protect our body from being exposed so that anyone who is passing nearby should not be able to see us, if I'm in a bad condition they were very effective they come and assist me, when men were trying to move around there, they were blocked so they maintained privacy and confidentiality throughout my presence during healthcare, the curtains were well closed and only one nurse was there when giving healthcare (Woman—Tanzania).

Incentives and allowances were offered to healthcare providers by management at several facilities in both countries; these were viewed generally as positive, helping providers feel valued and motivating them in their work. Meals were provided to nurse-midwives on duty across all facilities in Malawi and some facilities in Tanzania, this was noted to be beneficial in saving time as they did not leave the facility to collect food and, therefore, leave women for prolonged periods:

…and the hospital decided that the labour Ward staff must be given hot meals during lunch hours and including the night, they always give us the hot meals so that we shouldn’t be going out so that the care we are giving to women shouldn’t be interrupted (Nurse—midwife—Malawi).

Also, the maternity leadership provide breakfast for all healthcare providers on duty so that they don’t go out often to look for food. This is good because it motivates the healthcare workers (Nurse—midwife—Tanzania).

Women, family members and healthcare providers also valued the importance of good hygiene and cleanliness for quality care. Lay participants at one study facility in Malawi and two facilities in Tanzania appreciated the use of sterile equipment and clean bed linen in the facilities.

Many women in some study facilities of Malawi and Tanzania indicated a wish to have support from family or a chosen companion during the birth. Although many facilities did not actively promote access to labour companions, individual staff often accommodated them on an individual basis, using screens and separate areas for privacy. In one facility in Malawi, the labour ward manager provided a private room for women who wanted male partners to remain with them.

……also, we encourage male companion for, we have a special room where the patient who came with the male companion were kept in that room………. Others should take that example that male companion is good because the woman also express herself in the presence of the husband (Labour ward manager—Malawi).

Both lay and healthcare providers’ participants recognised that increased resources including medical supplies and hospital building improvements contributed to improving care overall, including dignity and respect. One healthcare provider noted the importance of co-operation at all levels in facilities.

And also, provision of adequate resources, because previously were issues of lack of resources but after sitting down with management, the leadership, the pharmacy people, they try their best to provide enough resources in our Labour ward since this is a busy maternity (Nurse—midwife—Malawi).

All participants, across both countries, acknowledged the need for further improvement in facility infrastructure, envisaging an optimal environment, which would have adequate buildings, curtains and screens and more space, which could reduce overcrowding and facilitate companionship during labour.

So, maybe if there were enough rooms, so that people should fit in, and then there should be spare beds without people. That would help us a lot. …the rooms should be enough; they should be able to protect (provide privacy) us at the time of delivery (Woman—Malawi).

A family member added—There should be the nurse, the patient and her guardian. If there are two beds, there should be something to screen them. They should work with their doctor, and so should the others… (Family member—Malawi).

Theme 3: supportive leadership

Participants appreciated the commitment of their governments and facility leadership to promoting provision of respectful care. In Tanzania, recent change of government was perceived as having led to general improvements in the health sector and maternity care.

I think the leadership has contributed, it seems the leadership is good that’s why it is like that……….I think another thing that has contributed to good services is our government to insist about saving mother and child’s lives ………such as a service of operation I think it has contributed at large (Woman—Tanzania).

Leadership was also influential at the facility level, for example, in promoting the development of policies and treatment guidelines. These were valued by healthcare providers in standardising practice and supporting decision-making in the clinical areas. Family members also recognised the positive impact of supportive leadership at the hospitals in improving care and outcomes for patients.

And the policies at this hospital, those who are in top positions give proper advice and they give proper explanations that, when a patient comes, you should treat them this way, take care of them properly (Family member—Malawi).

Healthcare provider participants valued supervision and mentorship, for example, from senior midwives and hospital matrons. In Malawi, consultant midwives were available to support less experienced midwives in practice. The consultant midwife had a ‘hands-on’ clinical role in the facility and provided role modelling, mentorship and clinical expertise to support other midwives, these midwives were highly respected by their peers. Healthcare providers across both countries valued the habit of discussion and debriefing after difficult clinical scenarios as opportunities for learning and reflection for nurse—midwives.

….and another thing is that there is adequate supervision in our facility. Even the matron, she comes and supervises. So, I think that is one of the things that has allowed us to provide respectful care (Nurse—midwife—Malawi)

Also, we have labour ward in-charge who keeps on reminding us every day and head of department sometimes comes for supervision to remind us about our policies and good practice (Nurse—midwife—Tanzania).

Good communication and feeling valued by the organisation were also important. Morning and monthly staff meetings in facilities were seen as important forum for discussing service provision:

There are monthly staff meetings where we discuss about work; these should be maintained (Nurse midwife— Tanzania).

The importance of supporting providers to enable them to provide effective care was consistently recognised at all levels across study facilities in both countries.

That person who supervises them is required to show love to the nurses who are working in that place, so that they themselves should also feel good when working (Woman—Malawi).

Healthcare providers’ participants identified supportive supervision, opportunities for reflective discussions and organisational commitment to well-being as important. Perceptions of a ‘blame culture’ was identified as a barrier to openness and progress.

We can say that, not just point to the faults or the mistakes that our providers are making, but also promote the good, like appreciating them for the good work they do (Medical doctor—Malawi).

Paying healthcare providers’ salaries in timely manner, increasing their salaries and giving additional allowances were identified as motivating them to provide optimal care. Non-monetary benefits, such as providing food when they are on duty, providing transport and housing near their working areas, were also identified as potentially helpful.

So, I think the hospital should try hard to appease the doctors and nurses and pay them quickly and on time because these people save a lot of lives (Woman—Malawi).

Theme 4: providers’ attitudes and behaviours

Demonstrating professional values through readiness, compassionate communication and commitment were considered key positive attributes for health workers. The lay participants across both countries valued the willingness of healthcare providers to provide care to women despite resource pressure when facilities were busy or when they were coming to the end of a shift.

The thing that I noticed when receiving healthcare is that the nurses were very sensitive and active, they can't see someone who is in pain and just leave her like that, they took positive steps to help her (Woman—Tanzania)

I had found a nurse who was on night duty and was about to knock off, but she did not accept that she was knocking off. She still gave me care; she examined me and cleaned me properly (Woman—Malawi).

Compassionate care was an important contributor to family member’s perceptions of positive experiences of their relatives at the study hospitals. For example, they identified nurses giving attention to babies in the neonatal unit when their mothers were unavailable. Also not leaving women alone for long periods, for example, during shift handovers was appreciated:

……during hand overs we always make sure that they (women and newborn) are not left alone; they are always with someone to attend to them (Nurse midwife—Malawi).

These values were identified as integral to professionalism and could be acquired through effective education to facilitate quality care:

I feel that it was because she was well trained in her job; that’s why she gave me care. …. There is nothing else because, by then, my guardian was not yet there, and that’s the only reason, that she was well trained but also, she (nurse) is a compassionate woman (Woman—Malawi).

Although most healthcare providers displayed some degree of professionalism, participants identified need for strengthening of core values to underpin improvements in care:

So, for me, my wish is that those nurses should also take us women as human beings, the way they are, because of the way we feel. They are also woen. If it’s a man, he also sees maybe his wife, the way she suffers (Family member—Malawi).