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Background The perceptions of midwives regarding Respectful Maternity Care (RMC) significantly influence the quality of care provided. This research aimed to investigate the level of perceived competencies and self-reported implementation of RMC among Kerala midwives during the childbirth process. Methods A cross-sectional study was conducted between May and June 2025, focusing on perceived competencies and self-reported practice on RMC among 146 midwives selected by convenience sampling from the different units of two hospitals in Kerala. The participants were midwives with at least one year of experience in their roles. To evaluate their perceived competencies and self-reported practice, assessed by the Midwives' Knowledge and Practice Scale, was administered with Cronbach's Alpha reliability of 0.86 and 0.829, respectively, on Respectful Maternity Care. A chi-square was employed to examine the association between the midwives' age, educational background, and work experience with their perceived competencies and self-reported practice on RMC. Result: The findings indicated that midwives in Kerala exhibited strong perceived competencies and self-reported practices of RMC in their care approach. The average scores for overall perceived competencies and self-reported practices of RMC were 110. 4±6.2 and 109.8 ±6.37, respectively. Midwives recorded overall good perceived competencies and self -reported practices on Respectful Maternity Care (RMC) during Childbirth. The analysis revealed that a positive correlation between the perceived competencies and self-reported practices of RMC among midwives is significant at the 0.01 level (p<0.05; 2-tailed). There is a significant association between research variables and education at the (p<0.05)0.01 level. Conclusions The study highlights strong perceived competencies and self-reported practices of RMC among midwives in Kerala, with education playing a significant role in these outcomes. Enhancing respectful maternity care necessitates the development of practical skills with adequate cognitive empowerment among midwives work in the maternal care unit
Keywords: Perceived competencies; self-reported practices; Respectful Maternity Care; Midwives; Health Facilities; Perceivedcompetencies; self-reportedpractices; RespectfulMaternityCare
Giving birth is a significant moment in a woman’s life,andeverywomandeservestoreceiverespectful treatmentduringlaboranddelivery.NumerousmidwivesunderstandtheideaofRespectfulMaternityCare (RMC),yettherecanbeadisparitybetweentheirunderstandingandactualimplementationinfacility-based environments.Maternalcarevariesbasedonfactors suchasinstitutionalbacking,personalattitudes,and theparticularchildbirthsetting.KeyelementsofRMC thatmidwivesshouldrecognizeandactivelytrytoincorporateinclude:encouraginginformedchoice,honoringwomen’sautonomy,deliveringcontinuoussupport,upholdingprivacyandconfidentiality,employing respectfullanguage,permittingthepresenceofcompanions,andtailoringcaretoindividualpreferences andculturalpractices[1]. Trainingforhealthprofessionalsandchangesatthesystemlevelcanassistin closingthegapbetweenknowledgeandthereliable applicationofRMCinhospitalenvironments.[2]The WorldHealthOrganizationendorsescompetencyasessentialformidwivestorendersafeanddignifiedcare. Onein5About20%ofwomenreportedmistreatment whilereceivingmaternitycare,and45%almosthalf (45%)ofwomen,heldbackfromaskingquestionsor sharingconcernsduringtheirmaternitycare[3].The studyexploredthatthefactorsinfluencingtheclinical decision-makingofmidwivesfindingthatmidwives’ knowledgeisgroundedinbasiceducationandtraining,useofguidelinesandprotocols,in-servicetraining,andcontinuousprofessionaldevelopment,readingjournalsaconsultationwithcolleagues[2]. Midwiveshavetheabilitytocreateandsustainasecureand welcomingbirthingatmosphereforwomenthrough practicesthatrecognizeandsupporttheirneeds.3Care providersemphasizedtheimportanceofunderstandingrespectfulmaternitycaretoensureoptimaloutcomesforwomen,families,andcommunities. However,giventhecomplexityofmaternitycare,itiscrucialforpolicymakers,administrators,andmidwivesto comprehendandappreciatethevariouselementsthat definerespectfulcare,asthisunderstandingcansignificantlyenhanceitssuccessfulimplementation[4].Addressingtheidentifiedcomponentsandfosteringacultureofrespectandcompassionwithinhealthcaresettingscangreatlyenhancecarequality,ensuringthatit isresponsivetotheneedsofwomenandrelatedpeople [4].Womenwhoexperiencerespectfulmaternitycare tendtohaveagreaterlikelihoodofdeliveringvaginally, feelingsatisfied,andhavingshorterlabordurations [5].Thisisduetothecontinuoussupportprovidedby midwivesduringchildbirth,whichformsacriticalelementofrespectfulmaternitycare.[6].andknowledge wives’associationsglobally[7].TheWorldHealthOrganization(WHO)highlightedin2018theimportanceof the quality of communication between women and their healthcare providers, viewing positive interactions as essential for favorable childbirth outcomes [8].Theresearchinvestigateshowmidwivesperceive andimplementrespectfulmaternitycarethroughout laborandchildbirth[9].Overall,midwivesareaware ofthesevenrightsofmothersandmaintainafavorable perspective on delivering respectful maternity care(RMC).Nonetheless,certainabusivebehaviorspersistamongmidwiveswhenofferingRMC,accompanied bysignificantchallengessuchasoverloadandinsufficientlabormonitoringsupplies.Itisrecommended tomodifythemidwife-to-clientratioandensurethe availabilityofnecessarymaterialsforlabormonitoring [10]. and should ensure logistics for alternative birthingpositionsandmaintainprivacy.Additionally, allmidwivesandhospitalstaffshouldparticipateinthe RMCtrainingprogramtopromotegoodpractices[11]. Encouragingrespectfulmaternitycarenecessitatesvitalinterpersonalandcommunicationskills,alongwith supportiveattitudesfrommidwives.Suchsupportencompassesemotionalassistancesuchascontinuous presence,physicaltouch,empathy,reassurance,positivereinforcement,andinformationregardinglabor progress.Itmayalsoinvolveguidanceoncopingstrategiesandprovidingcomfort[12].Trainingfocusedon evidence-basedpractices,supportandtrainingformidwivesonRMC,sufficientsuppliesandequipment,and redesigningthewardtoincludeprivatedeliverysuites forbirthcompanionsandprivacyarealsonecessary [13]. Policiesandattitudeseitherhavethepotential tosupportorobstructRMC[14].Theseinsightsmight contributetoanationwidemidwiferysurvey,educationalcurricula,andreformsinhealthsystemstofacilitatelessrestrictivepoliciesandenvironments.Incidentsofdisrespectfulcareduringchildbirthhavebeen notedbyhealthcareworkers,[15,16]thisleadstovaryingpracticesdependingonindividualmidwivesand thespecifichospitalcontext,withsomemidwiveseffectivelyemployingpatient-centeredmethods,while othersmayencounterdifficultiesinfullyadoptingRMC practicesduetosystemiclimitations. Thestronginitiatives to enhance institutional policies, resources, training,andsupervisionofhealthcareprofessionals regardingwomen’srightsduringchildbirthtoimprove thequalityofcareandfosterpositivebirthexperiences [17]. Measuring the RMC during childbirth can be a powerfultooltohelpendtheabuse. ThestudyhighlightsalldomainsofRMCfromthemidwives’viewpoint andtheirpractices. Improvingtheinstitutionalpolicies,resources,andtrainingofhealthcareprofessionalsaboutwomen’srightsduringchildbirthwouldhelp strengthenthequalityofcaresothatwomenreceive evidence-basedcareandensurepositivebirthexperiences[16].Disrespectandabuseperceivedbymothers admittedinmaternityareas,harshandannoyingmaternitycarebehaviorintermsofphysical,verbaland emotionalaspectwhichhasbeendefinedinvarious formsandthereisgapinknowledgeandpracticeof RMCamonghealthworkers[17]. Designingtailored interventions, policiesandprogramsforvariousdynamicsystemsandregularmonitoringandevaluation willhelpinachievingRMCatthenationallevel[18]. Thiswillnotonlyaddressmaternalmortalitythrough thedeliveryofcarebutalsofocusonthequalityofcare withamoredefinedandstandardizedapproach[19]. Sometimes,healthcareprovidersmaynormalizedisrespectfultreatmentduringchildbirth,whichintrudes onbasichumanrights.Immediateactionisneededto improveandsupportRMCasacriticalcomponentof maternalcarebyadoptingstandardizedmeasures,and traininghealthcareproviderstopracticethecodeof ethicsasacorecomponentofRMC[20,21].Thepresent studyemphasizestheassessmentofmidwives’awarenessandpracticeonRMCduringinstitutionaldelivery. Thereisaneedofbettertrainingprogramsforhealth professionalstoimplementRMCtofillthegapinknowledgeandpracticeofRMCamongHealthworkerssoas toeventuallyimprovethemidwives’competenciesand practiceaboutRMC,anditmaycontributetobettermaternalhealthoutcomes.
Aquantitativeapproachwasadoptedforthisdescriptiveresearch.Thiscross-sectionalstudywasaimedto assesstheperceivedcompetenciesandself-reported practiceofmidwivesregardingRespectfulMaternity Care(RMC)duringchildbirth,conductedfromMayto June2025attwoprivateteachinghospitalsinIdukki andKannurdistrictsofKerala.
The study population comprised all midwives employedinthetwohospitals,totaling146participants. Allmidwivesfromtheselectedhospitalswereinvited totakepartinthesurvey.Thosewhoconsentedand signedtheinformedconsentformparticipatedinthe study.Participantshadtomeettheinclusioncriteriaof beingmidwivesemployedinthelaborunit,havingobtainedamidwiferyacademicdegreeordiploma,and possessingatleastoneyearofworkexperienceorhavingpreviouslyworkedinthesameunit.
The total accessible population was utilized for the study.Datafromthebothhospitalsshowsthatthere arecurrentlyonehundredandninety-seven(197)midwives in the selected hospitals. Midwives with less thanoneyearofexperienceornoexperienceanduninterestedwereexcluded,totaling51midwives. The selectionofmidwiveswasdoneusingaconsecutive samplingmethod,resultingin146midwivesincluded fromatotalof197workingatthehospitals,while51 wereexcludedfromthestudy.Interviewstookplace inconvenientlocationslikethenurses’stationorthe classroom within the hospitals. For data collection tools included a questionnaire for demographic informationandanopen-accessstandardizedversion of 5-point Likert scale on the Midwives’ Knowledge andPracticeScaleonRespectfulMaternityCare(MKP- RMC),[27,28,34]whichwasusedtoevaluatemidwives’ perceivedcompetenciesandself-reportedpracticeon RMC.Reliabilityofthetoolsis0.86and0.829respectively.
The questionnaire on demographic data consists of 6items,RespectfulMaternityCare(RMC)perception andpractice,eachsectionwith23items,theseencompassedvariousaspectsofRMCtoexecutecareduring laboranddelivery. Foreachitem,theresponsewas scoredasstronglyagree(5),agree(4),don’tknow(3), disagree(2),andstronglydisagree(1)ontheawareness sectionandalways(5),often(4),sometimes(3)rarely (2)never(1)onpracticeofRMC.Totalscorewas115in eachsection.Ascoreofmorethan90%wasperceived asgoodcompetenciesandself-reportedpracticeon RMC,70%to90%averageRMC,andlessthan70%poor RMC.ThecontentvalidityindexoftheRMCknowledge andpracticequestionnairewas0.85.Thereliabilitywas establishedbyCronbach’salpha,whichwas0.86and .829respectively.Theperceivedcompetenciesandself -reportedpracticeofRMCwereassessedusingastructuredquestionnairewith46itemsoftwoaspects.The pilotstudywasconductedwith15memberstofindout thefeasibilityofthestudy.
Thedatacollectionofthisstudywasconductedafter gettingethicalclearancefromtheethicalcommittee andwrittenpermissionfromtheauthorityconcerned thedatawascollectedfromselectedmidwivesofassignedhospitals.Sampleselectionwasdonebyusinga non-probabilityconsecutivesamplingtechnique,data collectedfrom1stMay1sttoJune30th2025. Allthe selectedparticipantswereaskedtogatherintheirrespectivenurses’stationorclassroom.Thenexplained thepurposeofthestudyandrequestedtoinformed consentandmaximumcooperationwithhonestyin fillinginquestions. Afterclarifyingtheirdoubtsand gettingalltheneededinformation,datawascollected fromeachsample.
ThecollecteddatawereenteredintoaMicrosoftexcel datasheetafterbeingreviewedforconsistencyand completeness. TheIBMSPSSStatisticsforWindows, version30.0,wasusedtoanalyzethedata,thatwasdescriptivestatisticsoffrequencies,percentages,graphs andtables.Dataonmidwives’perceivedcompetencies andself-reportedpracticeofRMCwasassessedusinga 5-pointLikertscalewhichwasconsideredasaninterval scale.Acompositescorewascomputedforallrespondentsusingtheirresponsestothe46items,assuming equalweightingoftheitems.Ascoreofonewasgiven fortheleastcorrectanswerandascoreof5wasgiven forthemostcorrectanswergivingaminimumscore of23andamaximumscoreof115forsection. Ininstanceswherethenegativeresponsewasthemostcorrectanswer,thereversewasthecase.Fortheproposed studythedataanalysismethodsare;Descriptivestatistics:Mean,percentage,andstandarddeviation,Kaul Pearson’scorrelationtestandchi-squaretestusedfor inferentialstatisticsassesstheawarenessandpractice forprovidingRMCbymidwivesinhealthfacilities.Participantsallprovidedwritteninformedconsentinan Englishlanguageoftheirpreferencepriortoadministeringsurveyquestionnaire.Allstudydocumentswere reviewedandapprovedbytheethicsreviewboardof institution.
Thetableaboveindicatesthatthemajorityofparticipantswerepermanentemployees,comprising63%, whiletheremainingwasontemporarycontracts. A notablepercentageofparticipantshadlessthanfive years(61%)ofexperienceinintra-partumcareunits. ThemajorityofmidwiveshadachievedaB.Sc.innursing(45.9%),withonly12.3%possessingaM.Sc.degree. Asignificantportionofthem(68.5%)weremarried,and 26%hadtwochildren.
Thehistogrampresentedaboveindicatesthat137midwives,accountingfor93.82%,wereratedashavinga goodlevelofperceivedcompetencies.
Thehistogrampresentedaboveindicatesthat136midwives,accountingfor93.12%,wereratedashavinga goodlevelofself-reportedpractices.
Thecross-sectionalstudyconductedbetweenMayand June 2025 among 146 midwives in two hospitals in Keralaprovidesvaluableinsightsintotheirperceived competencies and self-reported practices regarding RespectfulMaternityCare(RMC)duringchildbirth.The findingsarediscussedbelow,withcomparisonstoprevioussimilarstudiestocontextualizetheresultsand highlighttheirsignificance.Thesamplewaspredominantlymarried(68.5%),withmostmidwiveshaving lessthan5yearsofexperience(61%)andpermanent employmentstatus(63%).Thesecharacteristicsmay influenceRMCpractices, asstabilityinemployment SLNO Variables 1 a)Single b)Married a)ANM b)GNM c)Bachelorinnursing d)MScinnursing e)PhDinnursing Workexperienceinthebirthunit(years) a)<5 b)5–10 3 c)11–15 d)16–20 e)21–25 f)>25 a0 4 b1 c2 d>2 5 a)Permanent b)Temporary
Table 2. Totalmeansscoreofperceivedcompetenciesandself-reportedpracticesonrespectfulmaternitycare amongmidwives n=146
1 Perceivedcompetencies 146 110.2808 2 Self-reportedpractices 146 109.8219
andpersonallifecouldcontributetobetterfocusand commitmenttoqualitycare.Notably,midwiveswith no children (37%) or two children (26%) were wellrepresented,whichmayreflectvaryinglevelsofempathyorunderstandingofmaternalneedsbasedon personalexperiences.However,thestudydidnotexplicitlyanalyzethisvariable’simpactonRMC.Thestudy foundthatmidwivesinKeralademonstratedstrong perceivedcompetencies(meanscore:110.4±6.21)and self-reportedpractices(meanscore: 109.8±6.37)in RMC.Thesehighscoresindicatethatmidwivesfeelconfidentintheirabilitytoproviderespectfulanddignified careduringchildbirthandreportconsistentapplicationofthesepractices.TheuseoftheMidwives’KnowledgeandPracticeScale,withCronbach’salphavalues of0.86forperceivedcompetenciesand0.829forselfreportedpractices,confirmsthereliabilityofthetool inassessingtheseconstructs.Thesevaluesalignwith standardsforacceptableinternalconsistency(0.7),suggestingrobustmeasurementquality.Similarstudies, suchasthosebyAfulanietal.(2019)inKenyaandTanzania,reportedmoderatetohighlevelsofperceived RMCcompetenciesamongmidwives,butself-reported Frequency Percentage
46 31.5 100 68.5
6 4.1 55 35.7 67 45.9 18 12.3 Nil Nil
89 61.0 29 19.9 17 11.6 9 6.2 1 .7 1 .7
54 37 28 19.2 38 26 26 17.8
92 63 54 37
6.20205 .201 -2.558 6.37418 .201 -2.019
practices were often lower due to systemic barriers likeunderstaffingorresourceconstraints.Incontrast, theKeralastudy’shighscoresforbothcompetencies andpracticessuggestasupportiveenvironment,possiblyduetobettertrainingprogramsorinstitutional policiesintheselectedhospitals[24,35].A2020study in Ethiopia by Shiferaw et al. found that midwives’ RMCpracticeswereinfluencedbytheirknowledgeand training.TheKeralastudy’ssignificantcorrelationbetweencompetenciesandpracticessupportsthis,indicatingthattargetedtrainingcouldbridgegapsbetweenknowledgeandapplication[36].Astatistically significantpositivecorrelation(p<0.05,2-tailed)was observedbetweenperceivedcompetenciesandselfreportedpracticesofRMC.Thissuggeststhatmidwives whofeelcompetentinRMCaremorelikelytoreport implementingrespectfulcarepracticesintheirwork. ThisfindingisconsistentwiththeTheoryofPlanned Behavior,whichpositsthatperceivedself-efficacyinfluencesbehavioraloutcomes.[42,43,44].Thechi-square analysis revealed a significant association between educationallevelandbothperceivedcompetencies andself-reportedpractices(p<0.05). Midwiveswith maternitycare n=146
Table 4. Associationbetweenperceivedcompetenciesofmidwivesanddemographicvariables n=146
Age <25 1 25-35 1 36-45 >45 3 Single Married ANM 6 GNM 53 3 1 3 Bachelorinnursing 64 MScinnursing 12 PhDinnursing Workexperiencein thebirthunit(years) <5 9 85 5–10 1 48 4 1 11–15 0 1 16–20 0 1 21–25 >25 a0 5 b1 c2 d>2 Permanent 1 Temporary
highereducationalqualifications,suchasBachelor’s (45.9%)orMaster’sdegreesinnursing(12.3%),likely reportedhighercompetenciesandbetteradherenceto RMCpracticescomparedtothosewithAuxiliaryNurse Midwife(ANM)(4.1%)orGeneralNursingandMidwifery (GNM)(35.7%)qualifications.Thisalignswiththeidea thatadvancededucationenhancesknowledge,skills, andconfidenceinapplyingpatient-centeredcareprinciples.Thesignificantassociationbetweeneducation andRMCoutcomesalignswithfindingsfroma2023 study in Nigeria by Okonofua et al., which showed
Perceivedcompetencies
Self-reportedpractices
Correlationissignificantatthe0.01level(2-tailed).
0 25 3 52 3 5.422 .143 6 50 1 8
3 85 1 .002 .964 8 50
3 19.784a .000
3 1.621 .655
2 52 2 26 3 3.451a .327 2 35 4 21
6 85 1 .002 .965 4 50
thatmidwiveswithhighereducationalqualifications weremorelikelytoimplementRMCprinciples. This maybeattributedtoadvancedcurriculathatemphasizepatient-centeredcare,communicationskills,and ethicalconsiderations,whicharecriticalforRMC[37]. WhiletheKeralastudydidnotexplicitlyreportasignificantassociationbetweenworkexperienceandRMC outcomes,thedistributionofexperience(61%with<5 years)suggestsarelativelyyoungworkforce. A2018 study in Ghana by Dzomeku et al. found that more experienced midwives were more confident in RMC
Age <25 1 25-35 1 36-45 >45 3 Single 1 Married ANM GNM 3 1 Bachelorinnursing MScinnursing PhDinnursing Workexperienceinthebirthunit(years) <5 5–10 4 11–15 16–20 21–25 >25
5 1
>2 6 Permanent Temporary
practicesduetocumulativeexposuretodiversechildbirth scenarios. The Kerala findings may differ due to the predominance of less experienced midwives, yettheirhighscoressuggesteffectivetrainingormentorshipprogramsinthesehospitals[39,45].Thehigh RMC scores in Kerala may reflect the state’s strong healthcareinfrastructureandemphasisonmaternal health,asnotedinstudiescomparingKerala’shealth outcomestootherIndianstates(e.g.,Thankappanet al.,2019).Unlikestudiesinlow-resourcesettings(e.g., Bowser Hill,2010),wheredisrespectandabuseinmaternitycarewereprevalent,theKeralamidwives’performancesuggestsaculturalorsystemicinclination towardrespectfulcare, possiblyreinforcedbystatelevelpoliciesorcommunityexpectations[38,40]
• TrainingandEducation:Thesignificantassociationwitheducationunderscorestheneedfor
0 25 3 52 6 9.583a .143 6 50 1 8
6 38 4 3.346a .502 8 93
1 5 1 54 6 16.921a .010 6 58 6 14
9 84 0 5 43 6 2.193a .901 1 1 1 1 1
1 6 46 0 2 26 6 7.322a .292 0 1 37 0 5 20
0 11 80 2 3.217a .200 1 5 49
continuousprofessionaldevelopment,particularlyformidwiveswithlowerqualifications(e.g., ANMorGNM).IncorporatingRMC-specificmodulesinnursingcurriculaandin-servicetraining couldfurtherenhancecompetenciesandpractices.
• PolicyandPractice:Thepositivecorrelationbetween perceived competencies and practices suggests that fostering midwives’ confidence through supportive supervision and feedback mechanismscouldimproveRMCimplementation. Hospitals should ensure resources and staffing levels support RMC practices, as systemicbarrierscouldundermineevencompetent midwives.
• Research Gaps: The study’s reliance on selfreported practices may introduce social desirabilitybias,asmidwivesmightoverreportadherencetoRMC.Futurestudiescouldincorporateobservationaldataorpatientperspectives tovalidatethesefindings. Additionally,exploringtheimpactofpersonalfactors(e.g.,number ofchildren)orworkplacecultureonRMCcould providedeeperinsights.
• TheuseofconvenientsamplinglimitsgeneralizabilitybeyondthetwohospitalsinKerala. A broader,randomizedsamplecouldstrengthen thefindings.
• Thestudydidnotexplorepatientoutcomesor perspectives,whicharecriticalforassessingthe actualimpactofRMCpractices.
• Thelackofdetailedanalysisonhowspecificdemographicvariables(e.g.,maritalstatus,numberofchildren)influenceRMClimitsthedepth ofinterpretation.
Thestudyhighlightsstrongperceivedcompetencies andself-reportedpracticesofRMCamongmidwives inKerala,witheducationplayingasignificantrolein theseoutcomes. Comparedtopreviousstudies,the findingssuggestthatKerala’shealthcarecontextmay provideaconduciveenvironmentforRMC,possibly due to robust training and systemic support. However,furtherresearchisneededtovalidatetheseselfreportedpracticesandexplorepatientexperiencesto ensurethatRMCtranslatesintomeaningfulimprovementsinmaternalcarequality.
Ethical permission was taken from the Institutional EthicsCommitteeofInstitution.CN/A/35/2025dated on 09.09.2025, and required administrative permissionswerereceivedfromeverysingleauthoritywherever necessary. Informed consent from the respondentswascollectedbeforetheinterviewtookplace.
Funding: Nil Nil