Table 1. socio-demographic data from individual interviews
The majority (70%) of participants who took part in the interview were aged between 25 and 35. Among them, 80% were male, and 60% had experience of up to only five years
Table 2. Demographic data from Focus Groups
About half of the participants in the FGD fell within the age range of 31 to 35 (49.5%). The majority of participants were midwives (72.5%), and approximately half of them had accumulated one to five years of experience working in maternity services.
Variables
|
Categories
|
Frequency
|
Percentage%
|
Age
|
25–30
|
11
|
27.5
|
31–35
|
19
|
47.5
|
36 and above
|
10
|
25
|
Sex
|
Female
|
30
|
75
|
Male
|
10
|
25
|
Midwife
|
29
|
72.5
|
Nurses
|
11
|
27.5
|
Experience in maternity
|
1–5 years
|
20
|
50
|
6–10 years
|
15
|
37.5
|
11 years and above
|
5
|
12.5
|
During thematic analysis, four themes and sub-themes emerged from the data:
1) Women centered care with Compassionate care, Privacy and confidentiality maintenance, Information provision and liberty in decision making, Effective communication, Family involvement, Cleanliness of environment, Equality care. 2)Professionalism compliance with Motivated staff, Teamwork, Continuous development, Quality work provision, Community trust. 3) RMC encounters 4) RMC sustenance
1. Women centered-care
1.1 Compassionate care
Healthcare providers emphasized the importance of showing compassion to mothers. They stressed the need to put themselves in the client's shoes, treat the mother with empathy, reflect on ethical considerations, ensure her confidentiality, care for her with a good heart, make the mother feel relaxed, and show love and hope. They added that truly compassionate service would be achieved if a doctor treated every mother as if she were his/her own mother, wife, or sister. HCP reported that performing episiotomy without anesthesia is no longer exist.
‘’We need to have a heart of love and patience. In maternity, there is hard work, but we should have the heart to love people. So first we should strengthen love in ourselves and then have the gift of patience … What we should do for the mothers to show them compassion first is to put ourselves in their position because if we put ourselves in their place.” FGD1
HCPs reported that mothers should understand that labor pain is natural and normal. HCPs support labor by reassuring the mothers, providing back massages, encouraging them to ambulate, and ensuring emotional well-being by offering comforting words. Service providers reported having insufficient knowledge about labor painkiller medications.
“An area where we have little knowledge is pain relief for the mother in labor. Pain management is not appropriately done but we teach them with the help of the Bible”. FGD 5
1.2 Privacy and confidentiality maintenance
HCPs stated that privacy is maintained by using curtains between beds, but they recommend the use of rooms because curtains sometimes do not ensure confidentiality. They reported that confidentiality is maintained during the handover process, labeling laboratory samples, and medical rounds, where they use medical terms, signs, and identifiers. In our study sites, participants reported that they no longer use printed files; instead, they utilize technology (such as open clinic) to store client information, with everyone having an individual password to log in. However, uncertainty about how to prevent maternity information from being accessed by providers from other services was expressed. On one study site, they reported that maternity is planned to be built with rooms therefore birth companionship will be possible.
“Mainly, we care about the information we give to the mothers, their information is confidential, and we care about privacy”. IDI, matron, female, 34 years
1.3 Information provision and liberty in decision making
Midwives reported that a mother has the right to request information and receive it, and she also has the right to make choices and express preferences. Participants reported that the rights and responsibility of the clients are written on the hospital wall. Some information for mother and neonatal care is being provided. Some participants mentioned that during reception, customer care services welcome the mothers, and allowed them to contact the representative of customer care services at any time during their stay in the hospital. Additionally, before being admitted, mothers are required to sign a consent form. Participants recommended that women's rights should be posted in a visible location for mothers to read.
“There is a customer care representative of the hospital, her photo and number are available, they call her if they can't find the matron if a person has a problem and brings it to customer care, it is solved quickly”. IDI, matron, female, 33 years
Participants emphasized that mothers have the right to make their own decisions before receiving care. A mother may not have knowledge about her health; therefore, HCPs should first provide all information to the mother by explaining the pros and cons, allowing her to make a decision, and then sign the consent.
“The care is central to women, not to us. She is the one who is going into the labor, she is the one who is going to bear any procedure that we are going to perform on her, so she has the right to refuse the treatment.”IDI, doctor, male, 30 years.
Participants reported that a mother has the right to choose the treatment; for example, she has the right to opt for a cesarean section without medical indication. The decision-making process for a mother's treatment should be done as quickly as possible so that HCPs can take action without unnecessary delays.
1.4 Effective communication
To facilitate communication between clients, service providers and hospital management, they have a suggestion box for clients to share their ideas. After reading these suggestions, they can make decisions accordingly. Additionally, in some hospitals, there is a book where clients can submit any eventual complaints and measures can be implemented when there is evidence of disrespect.
There is a way to handle incidence of disrespect.
‘’When there is an incidence of disrespect; We have a quality book, whoever is found to have happened is approached and discussed and we can register her in the book and also resolve issue with the victim. If happens for the second time, the case is presented to the higher authorities for punishment’’ IDI, matron, female,33 years
To handle disrespect issue, HCPs from one hospital reported that they manage it at their level or they refer to mental health services
“If a client is physically or psychologically harmed by a healthcare provider, the first is to prevent the spreading of information. In our measures, we have a team leader who must handle the problem and approach the family to find a solution. If it is beyond our control, we can use the mental health service to help us.” IDI, matron, male,27years
To improve client-provider communication, providers should explain the labor process to the clients, giving them time to ask questions freely. Listening to them and providing feedback during this process helps to establish trust.
‘’If you have confidence in explaining to the mother how things are going, and when you explain directly to her, she immediately trusts you’’. IDI. Doctor, male, 37 years
Participants advised HCPs first to introduce themselves to the mother. Taking time to read the client's file and talking with the client helps avoid harm. Explaining everything to the mother, including information on the baby's care, lab tests, and results, is crucial. Participants emphasized the importance of consented care, stating that service providers should explain everything they do and its significance, ensuring that mothers also understand. Providers should also clarify what is and is not allowed in the hospital, explaining their rights and responsibilities. They added that sometimes it is challenging to find time to provide all explanations to the mother.
“First we respect her rights. Respecting the right of the mother is to listen to her, to explain to her what she wants to know.”FGD1
1.5 Family involvement
HCPs argue that a mother has the right to involve her family in her care process, and service providers help the mother to achieve that. Midwives used to involve a birth companion to assist in the mother's care. However, the infrastructure hinder the birth companion from staying with the mother during the second stage of labour and is a significant challenge.
“The mother has the right to involve her family in the treatment when she wants, so that the male companion can come if she asks us, but when she doesn't ask, we have to treat her according to her rights.” FGD 3
1.6 Cleanness
Service providers argue that they encourage mothers to maintain personal hygiene. For infection prevention, HCPs used to request mothers to wear diapers during labor to prevent spreading of vaginal leakage, however, some mothers with traditional beliefs resist wearing those diapers. Providers ensure the cleanliness of beds and rooms and encourage mothers to maintain personal cleanliness as well. Cleanliness in the service is maintained, and there are cleaners specifically for the maternity ward and follow waste management measures. There is a daily cleaning schedule, as well as total cleaning. They stated that cleanliness should be a cultural norm.
‘’It is crucial to keep the hospital clean. To keep it going, everyone in the service is responsible for the mother's hygiene and not just the nurse’’. IDI, Doctor, male, 37 years.
Participants recommend providing clean water and soap for clients, along with outlining plans for bathing and bed making. They also suggest requesting mothers to come with their own hygienic supplies.
1.7 Equality care
Service providers echoed that they provide equal care to all women, accepting them as they are without considering their socio-economic status. However, they reported that educated mothers understand things more simply and quickly than others. Participants questioned why previous findings on quantitative research conducted on mothers reported that mothers who delivered by caesarean section perceived as being more respected than those with a normal delivery. They pointed out that a caesarean section is performed by a team, whereas in a normal delivery, the mother is cared for by one or two persons. Thus, a mother may simply be biased, thinking that being cared for by a team is a sign of respect.
‘’For mothers who delivered by caesarian section; it's not a procedure that is performed by one healthcare provider. There are many, anesthesiologists, and obstetricians... there are many. In the operating room you find 4 to 5 people around you; this leads mother to think she is really cared for. But for vaginal delivery, there is only one person. “ FGD 2
In addition, they reported that in a cesarean section, the mother is given pain medication before, during, and after the procedure. In contrast, during vaginal delivery, the mother may struggle to cope with labor pain, leading to feelings of giving up, and sometimes mothers are mistreated in the effort to save the baby.
2. Professionalism compliance
HCPs reported that their profession is a vocation and not like other professions. The love for the profession and respect for the oath are considered very important. Midwives reported that they relate their practices to what they learned in school. Furthermore, they learn from their experiences and avoid repeating past incidents. HCPs reported conducting client interviews and sharing client feedback with the staff. In meetings, the unity manager shares what is appreciated and critiques themselves. Employees know they should provide good services and be safe and calm in difficult situations. There is a culture of prioritization involving triage and starting with emergency cases. The challenge is a large number of clients and an insufficient workforce. There is a culture of listening to the client's complaints and making incident reports if they occur.
‘’We have established a culture among the staff that if our clients complain, you should not tell them that I can't help them, but you should listen to them, help them and give them advice” IDI, matron, 34 years
2.1 Motivated staff
The matron reported that in order to motivate the team, they have established solidarity and social activities among the maternity team, midwives organize and attend social events of their colleagues, such as wedding ceremonies and birth events, and even visit colleagues in difficult moments. They added that what keeps them in their career is the feeling that they are saving people, and when mothers are happy, HCPs also become happy (a positive cycle). Participants suggested ways to motivate the staff, such as providing tea or even food to decrease work stress and burnout, as well as rewarding and appreciating the best employees in public.
“When an employee does something good, you should praise her. Appreciating her is one thing, don't give her money because she is being paid, but showing her that you value what she did, this is also a motivation’’. IDI, matron, 33 years
2.2 Teamwork
The participants reported that teamwork is key and everyone in a team should be aware of their limitations and ask for help so that the mothers can achieve better outcomes and happiness. The task allocation schedule exercise is flexible, considering every staff member's issues without compromising the work. They advised if the health personnel don't feel well, it's better to communicate their feelings to their colleagues, and the staff should be attentive to those feelings to prevent any negative mood from affecting the mothers.
“There are times when a midwife comes with problems. We should know who has a problem so that it can disturb the client's feelings, and we assign her to a place where she will not meet people’’FGD 4
2.3 Continuous development
Some midwives have gotten RMC training. One matron requested to have continuous professional courses at the hospital or at school. The training can be organized by the hospital or the Ministry of Health. Midwives need the opportunity to receive full scholarships to upgrade their educational level.
“Here we have midwives who have been around for more than 15 years, and the healthcare system is being updated. Therefore, for mothers to receive quality care, it is essential to increase their knowledge.” IDI, matron, male,27 years
2.4 Quality work provision
Participants reported that accountability is needed to sustain the quality of care. HCPs emphasized their pride is getting a healthy baby and a healthy mother. Planning for pregnancy was highlighted as a key to a successful outcome. Participants appreciated that neonatology rooms are available. Participants stressed the importance of avoiding carelessness, implementing strict labor monitoring, following the partograph, and complying with accreditation guidelines. Hard copies of protocols are available and HCPs are able to check online for national guidelines when they encounter challenges. These hospitals are in the process of accreditation to improve the quality of services. Some HCPs reported that they have regular meetings and audits to monitor and evaluate the standards. Employee evaluation has a significant impact on RMC provision. Every staff member receives a bonus based on competence-based performance (PBF), this motivates them to make an effort to work better.
In hospitals, a survey on customer satisfaction is usually conducted, and recommendations based on the feedback are implemented. The project on quality improvement conducts evaluations every month. Protocols from the Ministry of Health are provided to every staff member.
“When a mother gives birth to a healthy baby, and all of them are healthy, it is our pride as midwives, and it is also the pride of the country and the community in general”. FGD 3
In the past, some the hospital building did not have immediate access to macadamized road. The HCPs appreciate the building of macadamized road to their hospital
“The road to this hospital was damaged, the cars used to get there were going to stack, and you found mothers complaining about it, but now the road is macadamized and enjoyable, and mothers feel respected.’’ FGD1
2.5 Community trust
The participants believe that when they provide friendly service, mothers will share their positive experiences repeatedly within the community, thereby restoring trust in the community.
“To gain community trust, we need a good outcome. Whenever you treat a woman with empathy, she will be the one to preach to others in the whole village. The one you treat well is the one who is going to change the population's mind’’. IDI, doctor, male, 30 years
There is a way to handle incidence of disrespect.
“We have a program called the patient's voice, as well as visit the community and listen to feedback and recommendations’’. IDI, matron, male, 32 years
3. RMC encounters
Labor pain medications are not yet available at all study sites. At the national level, protocols on labor pain medication are available but are only followed in tertiary hospitals in city. However, doctors in our study sites may not have the necessary skills to administer subdural anesthesia. In the postpartum period, minor painkillers like paracetamol and tramadol are administered.
‘’There are labour pain management protocols that have been developed at national level, but the nature of the hospital does not allow doctors to give labour painkiller drugs. Still, in our hospitals in Rwanda, we do not have enough doctors to care for the mother who has been given subdural anesthesia.” IDI, doctor, male, 35 years
Participants reported that mothers are taking traditional medications which can leads to maternal and neonatal adverse outcomes.
“Although it is not scientifically proven, we do not know what key ingredients are included in traditional medicines, sometimes you find that mothers are saying they help them, but they can also harm the condition of the baby in the womb.’’ IDI, doctor, male, 35 years
Among reported RMC hindrances are insufficient labour wards, sometimes birth companions have fear seeing mothers screaming and don’t understand it. Most of maternity services have insufficient doctors and midwives, overloaded clients, insufficient equipment like 1CTG per 20 clients, lack of private room. In addition, available rooms are built in close proximity so that one person can hear one another; which hinder confidentiality, privacy and staying with birth companion. Insufficient beds where 2 or 3 mothers share one bed have been reported. One matron reported that there is staffing plan that shows the workload and they advocate to the Ministry of Health to increase the number of midwives.
Service providers argue that mostly it is difficult to explain to the mothers and meet their level of understanding because many of mothers are uneducated. Providers from one hospital reported that obtaining clean water in the hospital is a problem but the issue has been reported to the hospital management to find a solution. Participants argue that the service can be good but client satisfaction depend on someone’s perceptions and personality.
4. RMC sustenance
To sustain RMC, participants emphasized to use empathy approach towards mother should be a cultural norm. They added that having self-confidence, regular supervision (with the clinical director overseeing technical staff and correcting any errors), being reminded of fundamental principles of human rights, and avoiding rushing in care provision, to avoid being busy on computers. The monitoring system should be reinforced, with regular quality improvement meetings and RMC refresher trainings. Workload adjustment, educating mothers on their rights at the entrance of the hospital. Equipment should be requested on time, and collaboration with maintenance services is crucial.
Health education should be conducted during antenatal care and at the community level to discourage the use of traditional medicine. Close monitoring during labor is essential, and increasing the number of workers and implementing shifts is recommended. Advocacy for motivation, such as salary increases or bonuses, as well as providing refreshments (tea breaks), is encouraged. There is a suggestion to increase the capacity of customer care services to be available 24/7. Participants also recommend organizing study trips to hospitals with high standards.
“I feel what could be done, there is something called a school trip, I felt that we can learn from other hospital by visiting to the model place …We can learn how is their maternity, and how they do maintain the privacy of their patients…. I feel that we should learn from others to see how they do it as said Kinyarwanda proverb "a bird that does not fly does not know where the corn is ripe". FGD 4
To enable mothers to have to experience normal delivery, mothers are encouraged to attend antenatal consultation, performing physical exercises, to attend the hospital early. In addition, participants emphasized that the mother should be called by name.
‘’If you call the mother by name when she sees you call her by her name; it makes her feel comfortable’’. FGD 1
Participants reported that, to gain community trust, they should be diligent and provide better service for better outcomes. The community should be informed about the services that are typically provided and those beyond their capacity. Additionally, HCPs should focus on positive changes, maintain positive aspects, learn from others, and constantly self-evaluate. HCPs should improve patient education and receive mothers well, as the client's first impression can play a role in regaining community trust. HCPs advised the hospital management to find out the community's perceptions of hospital services
Many participants suggest increasing the staff, especially midwives, for performing normal deliveries, training newcomers, and improving the buildings, particularly phasing out the use of curtains. Some participants suggested using soundproofing to maintain the confidentiality of mothers. They recommended using rooms with soundproofing instead of curtains to ensure patient information cannot be overheard by other patients.
They recommended monitoring the mother adequately and teaching her how to behave, position, and breathe during labor. It is suggested to procure enough equipment like CTG machines based on the number of clients, ensure an adequate number of beds, and supervise cleanliness in the hospital. Participants emphasize doing the work with a heart of love, reinforcing awareness of women's rights on radio or other platforms, and conducting RMC sensitization in the community. They advise to avoid retaining mothers in the hospital when they fail to clear the medical bill.