Respectful maternity care delivered within health facilities in Bangladesh, Ghana and Tanzania: a cross-sectional assessment preceding a quality improvement intervention.

Objective: To assess respectful maternity care (RMC) in health facilities.

Design: Cross-sectional study.

Setting: Forty-three (43) facilities across 15 districts in Bangladesh, 16 in Ghana and 12 in Tanzania.

Participants: Facility managers; 325 providers (nurses/midwives/doctors)-Bangladesh (158), Ghana (86) and Tanzania (81); and 849 recently delivered women-Bangladesh (295), Ghana (381) and Tanzania (173)-were interviewed. Observation of 641 client-provider interactions was conducted-Bangladesh (387), Ghana (134) and Tanzania (120).

Assessment: Trained social scientists and clinicians assessed infrastructure, policies, provision and women's experiences of RMC (emotional support, respectful care and communication).

Primary Outcome: RMC provided and/or experienced by women.

Results: Three (20%) facilities in Bangladesh, four (25%) in Ghana and three (25%) in Tanzania had no maternity clients' toilets and one-half had no handwashing facilities. Policies for RMC such as identification of client abuses were available: 81% (Ghana), 73% (Bangladesh) and 50% (Tanzania), but response was poor. Ninety-four (60%) Bangladeshi, 26 (30%) Ghanaian and 20 (25%) Tanzanian providers were not RMC trained. They provided emotional support during labour care to 107 (80%) women in Ghana, 95 (79%) in Tanzania and 188 (48.5%) in Bangladesh, and were often courteous with them-236 (61%) in Bangladesh, 119 (89%) in Ghana and 108 (90%) in Tanzania. Due to structural challenges, 169 (44%) women in Bangladesh, 49 (36%) in Ghana and 77 (64%) in Tanzania had no privacy during labour. Care was refused to 13 (11%) Tanzanian and 2 Bangladeshi women who could not pay illegal charges. Twenty-five (7%) women in Ghana, nine (6%) in Bangladesh and eight (5%) in Tanzania were verbally abused during care. Providers in all countries highly rated their care provision (95%-100%), and 287 (97%) of Bangladeshi women, 368 (97%) Ghanaians and 152 (88%) Tanzanians reported 'satisfaction' with the care they received. However, based on their facility experiences, significant (p<0.001) percentages-20% (Ghana) to 57% (Bangladesh)-will not return to the same facilities for future childbirth.

Conclusions: Facilities in Bangladesh, Ghana and Tanzania have foundational systems that facilitate RMC. Structural inadequacies and policy gaps pose challenges. Many women were, however, unwilling to return to the same facilities for future deliveries although they (and providers) highly rated these facilities.