Work

Respectful care during childbirth and educational inequities: a cross-sectional survey using a multidomain index across four hospitals in Malawi

Year: 2026

Type: article

Abstract: ABSTRACT: OBJECTIVE: This study aimed to apply a validated multidomain respectful maternity care index to assess women’s reported childbirth care experiences across four hospitals in Malawi, and to examine how reported less respectful maternity care varied by maternal education. DESIGN: Cross-sectional survey nested within the ALERT implementation research programme. Data were analysed using descriptive statistics and logistic regression, with sensitivity analyses using continuous outcome, modified Poisson and narrower abuse-focused outcome models. SETTING: The study was conducted in four high-volume secondary-level maternity units in Malawi’s Central Region, including three public facilities and one faith-based facility. PARTICIPANTS: 1004 postpartum women who gave birth in participating hospitals to infants weighing at least 1000 g or at a gestational age of at least 28 weeks. Data were collected between December 2021 and March 2024 across five survey rounds. PRIMARY OUTCOME MEASURES: The primary outcome was reported less respectful maternity care, measured using a validated composite score covering absence of abuse, privacy and confidentiality, dignity and respect, communication and supportive care, social support and the hospital environment. Scores were expressed as a percentage of best possible care and dichotomised at the 25th percentile (≤84.5/100). Individual respectful care indicators, including verbal abuse, privacy violations and non-consented care, were also assessed, alongside variations in reported care experiences across maternal educational levels. RESULTS: Overall, 16% of women were classified as reporting less respectful maternity care based on the composite score. Verbal abuse was the most frequently reported form of mistreatment, while non-consented care, neglect and privacy violations were less common; physical abuse and bribery were rare. Women with secondary or higher education had higher odds of reporting less respectful maternity care than women with primary or no education (adjusted OR 1.48, 95% CI 1.02 to 2.15; p=0.04) defined as being in the lowest quartile of respectful maternity care scores. Sensitivity analyses using the continuous respectful maternity care score and modified Poisson regression yielded similar evidence of an association with education, whereas no association was observed for the narrower abuse-focused outcome. CONCLUSION: Less respectful maternity care remains a concern in Malawi. Women with secondary or higher education had higher odds of reporting poorer respectful maternity care. This association may reflect differences in expectations, recognition, reporting or true experiences of care, which could not be distinguished in this study. Research should examine education-related reporting differences, while reforms strengthen communication, accountability and maternity infrastructure.

Source: BMJ Open

DOI: 10.1136/bmjopen-2026-118574