ARTICLE

 

A conceptual framework to promote respectful maternity care

 

 

P Lunda^I; CS Minnie^{II, III}; W Lubbe^IV

^IMNSc, PhD; School of Nursing, Faculty of Health Sciences, North-West University, South Africa
^IIMCur, PhD; School of Nursing, Faculty of Health Sciences, North-West University, South Africa
^IIIMCur, PhD; School of Nursing, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
^IVMTech, PhD; School of Nursing, Faculty of Health Sciences, North-West University, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND: This study presents a conceptual framework for respectful, woman-centred maternity care, integrating insights from the literature, systems theory, and critical theory. The framework incorporates healthcare institution and provider factors, ensuring dignity, respect and high-quality care throughout the maternity experience
OBJECTIVES: To outline the development process of this framework, which serves as a foundation for promoting respectful maternity care (RMC) in South Africa's public healthcare settings
METHODS: A theory-generative methodology was applied, using both inductive and deductive strategies to derive key conclusions, ensuring a comprehensive approach to theory construction
RESULTS: The framework identifies and describes essential concepts that foster synergy in promoting RMC. By integrating diverse knowledge sources, it establishes a strong theoretical foundation, linking its principles to RMC and broader quality healthcare standards
CONCLUSION: The conceptual framework provides a structured approach for enhancing maternity care through a woman-centred perspective. It underscores the value of combining multiple viewpoints to inform maternity care strategies, aiming to improve the overall maternal experience and healthcare outcomes

Keywords: conceptual; framework; woman-centred; respectful care; system; theory.

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Respectful maternity care (RMC) is a vital element of high-quality maternal health services, prioritising the dignity, autonomy and privacy of women, as well as their right to receive care that is free from mistreatment or harm during childbirth. Rooted in human rights principles, RMC asserts every woman's right to equitable and dignified healthcare, regardless of her background or circumstances.^[1] The World Health Organization (WHO) has identified RMC as essential to enhancing maternal and newborn health outcomes.^[2] RMC upholds principles that protect bodily autonomy and integrity, and supports positive interactions between patients and providers. Evidence indicates that it helps achieve improved outcomes for mothers and newborns by fostering trust, strengthening the patient-provider relationship, and encouraging women to give birth in health facilities.

Despite international efforts to improve maternal health, many women continue to report instances of disrespect and abuse (D&A) in health facilities. These include verbal assaults, neglect, physical mistreatment and refusal of care.^[3] Such experiences not only infringe upon women's rights but also deter them from seeking facility-based care, undermining confidence in the healthcare system. Consequently, RMC has become a central focus in the effort to improve care quality and maternal health outcomes. Current approaches emphasise woman-centred models that accommodate individual needs, support shared decision-making, and address systemic inequities in healthcare delivery.^[2] However, implementing RMC remains a challenge, hindered by limited resources, weak accountability mechanisms and insufficient training for providers. Effective advancement of RMC requires comprehensive strategies that target healthcare worker attitudes, institutional norms and community-level involvement to guarantee that all women receive respectful, safe and empowering care.

Although global advocates such as Human Rights Watch^[4] and the WHO^[5] have urged for the eradication of D&A during facility-based childbirth, such violations of women's rights persist in many maternity care environments. While the global perspective underscores the gravity of the problem, the conceptual framework in the present study focuses specifically on the context of public maternity care in South Africa (SA).

In SA, the need for RMC is deeply influenced by the country's sociohistorical and systemic context. The enduring effects of apartheid and entrenched structural inequalities continue to shape healthcare delivery and interpersonal dynamics in maternity settings.^[6-8] Research by Jewkes et al.^[9] and Dutton et al.^[10] highlights ongoing patterns of disrespect, abuse and neglect during childbirth, reflecting entrenched social hierarchies, gendered power relations, and chronic resource limitations. These issues reinforce the necessity of integrating RMC principles into national strategies for improving quality, accountability and equity in maternal care.

Several SA initiatives have responded to this need, such as the Clinical care, Labour ward management, Eliminate barriers, Verify care, Emergency obstetric simulation training, and Respectful care (CLEVER) initiative in Pretoria, which has enhanced communication, teamwork and patient satisfaction.^[11] The Essential Steps in Managing Obstetric Emergencies (ESMOE) programme embeds RMC principles to foster empathy and responsiveness among healthcare providers.^[12] The Embrace movement amplifies women's voices and advocates for equitable, woman-centred care.^[13] Additionally, the National Integrated Maternal and Perinatal Care Guidelines^[14] now include a dedicated chapter on RMC, signalling growing national commitment to respectful and compassionate maternity care.

Although this article is largely conceptual, situating it in the SA context underscores the ongoing need for transformation in maternity settings, as well as the progressive advances being made toward reshaping maternity care. Incorporating these local perspectives enhances the relevance of the proposed framework and aligns it with broader national and global efforts to promote quality, equity and human dignity in childbirth.

 

Methods

A theory-generative methodology was utilised, incorporating both inductive and deductive approaches to draw from existing literature and theories, resulting in a comprehensive and integrated conceptual framework. According to Tamene,^[6] a conceptual framework provides the foundational structure for exploring and solving a research problem. Whether depicted narratively or schematically, it maps out the components of an intervention and its application in practical settings, identifying essential concepts, factors, and their interconnections.^[15] This framework was developed through the integration of theoretical perspectives, existing literature, and empirical evidence.^[16,17]

The framework development, based on Hughes et al.,^[16] started by defining the research problem to establish focus. Key concepts were identified, and their relationships analysed for coherence. A theoretical base was chosen or created to support the structure. The framework was then built; the core concepts were aligned with research objectives for relevance and application.

Theoretical foundations

Systems theory

The healthcare system is viewed as a dynamic and complex entity composed of interdependent and interconnected subsystems, including individuals, institutions, infrastructure and resources, all working collectively to serve population health needs.^[18] The effectiveness of the system relies on the harmonious functioning of these parts, with any breakdown in one component potentially affecting the whole.^[19] Sustaining efficiency requires adaptation to evolving practices and conditions.^[20] The subsystem examined in this study is maternity care.

Critical theory

Critical theory critiques social structures that perpetuate inequality and marginalisation, especially for vulnerable populations.^[21] In the context of maternity care, it uncovers systemic barriers affecting women during pregnancy, childbirth and the postpartum period, advocating for autonomy, fairness, and improved maternal and newborn health. Critical theory also promotes collaborative approaches involving healthcare workers, policy-makers, community representatives and women, to support woman-centred and respectful care.^[22]

The conceptual framework

The woman-centred care model is transformative in that it promotes dignity, respect and high-quality care throughout the maternity journey. It responds to the pervasive problem of D&A in healthcare settings, particularly in under-resourced environments, by focusing on women's autonomy and informed choice.^[23]

Core concepts

The framework is based on four principal constructs: prerequisites, care environment, woman-centred processes, and outcomes.^[24] Prerequisites refer to the personal attributes of healthcare professionals, including empathy, professionalism and cultural sensitivity, which are essential to minimising disparities in care. The care environment involves institutional components such as infrastructure, leadership quality and teamwork, all of which affect the standard and fairness of care delivery, woman-centred processes encompass key principles such as privacy, respect, autonomy, trust, effective communication, and active participation in decision-making, and expected outcomes focus on measuring the success of RMC interventions, with RMC being the main desired result.^[24,25]

To implement this model effectively, it is essential to address underlying structural barriers, improve staffing and infrastructure, and embed a human rights perspective into all aspects of care.^[24,25] Enhancing support for healthcare providers through mentorship, mental health support and continuing education can help prevent burnout and encourage ethical and compassionate practice.^[3] By embedding these strategies in policy and practice, health systems can ensure that respectful, equitable and empowering maternity care becomes the standard, ultimately improving maternal health outcomes on a broader scale. The relationship of these constructs is outlined in Fig. 1.

 

Discussion

The woman-centred conceptual framework provides a critical approach to addressing systemic and interpersonal challenges in maternity care, particularly in low-resource settings. Discriminatory care persists across many low- and middle-income countries (LMICs), including SA, owing to entrenched systemic inequities and sociocultural power imbalances.^[7-9] While D&A during childbirth are well documented, few studies examine root causes such as provider stress and burnout.^[4]

This framework emphasises the care environment, including infrastructure, institutional culture, leadership and interprofessional dynamics. The divide between SA's public and private healthcare sectors exacerbates inequitable access.^[7-9] Strengthening the care environment and reinforcing dignity, autonomy and cultural respect are essential. A human rights-based approach, informed by context-sensitive strategies, ensures that maternity care is equitable, empowering, and clinically sound.^[1,2,23]

Study strengths and limitations

The woman-centred conceptual framework offers a holistic, rights-based approach to maternity care, emphasising respect, autonomy and cultural sensitivity. Its strength lies in integrating individual, interpersonal and systemic elements to promote empathetic, respectful care, especially vital in low-resource settings. However, real-world implementation is challenged by structural barriers such as inadequate staffing and infrastructure, entrenched power dynamics, and provider burnout. In LMICs, limited evidence exists on effective, scalable interventions. Without strong leadership and accountability, the framework risks being aspirational rather than actionable, highlighting the need for context-specific strategies and systemic reform to ensure meaningful impact.

 

Conclusion

Respectful care in maternal and reproductive health is essential to achieving positive outcomes and fostering trust between patients and healthcare providers. RMC settings emphasise treating individuals with dignity, compassion and autonomy, ensuring that their rights and choices are upheld throughout care. This approach combats disrespectful practices such as discrimination, abuse and neglect, which can negatively affect patient wellbeing. Emphasising empathy, communication and patient empowerment, respectful care fosters a supportive and safe environment.

Data availability. Not applicable.

Declaration. The research for this study was in fulfilment of the requirements for PL's PhD in Health Sciences with Nursing Science degree at North-West University.

Acknowledgements. None.

Author contributions. The lead author (PL) conducted the research, and co-authors CSM and WL checked the process.

Funding. None.

Conflicts of interest. None.

 

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Correspondence:
P Lunda
petronella.lunda@nwu.ac.za

Received 15 August 2025
Accepted 27 November 2025