Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: A qualitative systematic review and thematic synthesis of women's perceptions and experiences

The psycho-social elements of labour and delivery are central to any woman's birth experience, but international efforts to reduce maternal mortality in low-income contexts have neglected these aspects and focused on technological birth. In many contexts, maternity care is seen as dehumanised and disrespectful, which can have a negative impact on utilisation of services. We undertook a systematic review and meta-synthesis of the growing literature on women's experiences of facility-based delivery in sub-Saharan Africa to examine the drivers of disrespectful intrapartum care. Using PRISMA guidelines, databases were searched from 1990 to 06 May 2015, and 25 original studies were included for thematic synthesis. Analytical themes, that were theoretically informed and cognisant of the cultural and social context in which the dynamics of disrespectful care occur, enabled a fresh interpretation of the factors driving midwives' behaviour. A conceptual framework was developed to show how macro-, meso- and micro-level drivers of disrespectful care interact. The synthesis revealed a prevailing model of maternity care that is institution-centred, rather than woman-centred. Women's experiences illuminate midwives' efforts to maintain power and control by situating birth as a medical event and to secure status by focusing on the technical elements of care, including controlling bodies and knowledge.