• Respectful maternity care (RMC) is a well-described, rational approach for improving person-centered and equitable intrapartum and postpartum care, but it lacks a standard definition, clear measurement method, or evidence of effectiveness.
• Two types of RMC frameworks described in the literature based on either (1) Disrespect and Abuse or (2) Rights-Based, have overlapping themes with components that reflect efforts to implement metrics to eliminate practices identified as disrespect or abuse, and initiatives to work toward healthcare systems and settings that focus on respectful care. Common themes include: freedom from abuse, consent, privacy, dignity, communication, safety, and justice.
• Based on analyses of psychometric properties presented in 24 validation studies, 10 tools were considered to have fair or good overall validity and two tools had poor overall validity.
• RMC tools have not been subject to widespread testing and no single validated tool stands out as the best measure of RMC. However, the intrapartum version of the Mother's Autonomy in Decision-Making (MADM) and Mothers On Respect index (MORi) tools, and the Childbirth Options, Information, and Person-Centered Explanation (CHOICES) index for measuring RMC demonstrate good overall validity and are most relevant to U.S. populations. The Revised Childbirth Experience Questionnaire (CEQ-2) also demonstrated good overall validity for measuring childbirth experiences and includes some RMC components.
• Components of tools identified as having good validity to measure RMC incorporated themes of privacy, dignity, respect, autonomy, and communication or shared decision making. Teamwork and communication (among providers, staff, patients and families) was not specifically described as part of an RMC tool; however, shared decision making was framed as a way to improve communication between patients and providers and may facilitate teamwork and communication.
• One randomized controlled trial from Iran evaluated the effectiveness of an RMC intervention and demonstrated lower rates of postpartum depression for RMC compared with controls (20% vs. 50%, p=0.001).
• No trials from the United States or settings applicable to clinical practice in the United States evaluated the effectiveness of RMC for any health, utilization, or patient reported outcome.
• Alongside the urgent need to implement RMC, goals for RMC must include further testing of reliable performance measures and consensus around a clear definition to help standardize care delivery to ensure RMC for all who are pregnant or postpartum.

Objective. To summarize current research defining and measuring respectful maternity care (RMC) and evaluate the effectiveness of RMC and implementation strategies to improve health outcomes, particularly for populations at risk for health disparities.

Data sources. Ovid MEDLINE^®, Embase^®, and Cochrane CENTRAL from inception to November 2022 and SocINDEX to July 2023; manual review of reference lists and responses to a Federal Register Notice.

Review methods. Dual review of eligible abstracts and full-text articles using predefined criteria. Data abstraction and quality assessment dual reviewed using established methods. Systematic evaluation of psychometric studies of RMC tools using adapted criteria. Meta-analysis not conducted due to heterogeneity of studies and limited data.

Results. Searches identified 4,043 unique records. Thirty-seven studies were included across all questions, including the Contextual Question (CQ). Twenty-four validation studies (3 observational studies, 21 cross-sectional studies) evaluated 12 tools for measuring RMC. One randomized controlled trial (RCT) evaluated RMC effectiveness. There were no effectiveness trials from settings relevant to clinical practice in the United States and no studies evaluating effectiveness of RMC implementation. For the CQ, 12 studies defined 12 RMC frameworks. Two types of frameworks defined RMC: (1) Disrespect and Abuse (D&A) and (2) Rights-Based. Components of D&A frameworks served as indicators for recognizing mistreatment during childbirth, while Rights-Based frameworks incorporated aspects of reproductive justice, human rights, and anti-racism. Overlapping themes from RMC frameworks included: freedom from abuse, consent, privacy, dignity, communication, safety, and justice. Tools that measured RMC performed well based on psychometric measures, but no single tool stood out as the best measure of RMC. The intrapartum version of the Mother’s Autonomy in Decision-Making (MADM), Mothers On Respect index (MORi), and the Childbirth Options, Information, and Person-Centered Explanation (CHOICES) index for measuring RMC demonstrated good overall validity based on analysis of psychometric properties and were applicable to U.S. populations. The Revised Childbirth Experience Questionnaire (CEQ-2) demonstrated good overall validity for measuring childbirth experiences and included RMC components. One fair-quality RCT from Iran demonstrated lower rates of postpartum depression at 6-8 weeks for those who received RMC compared with controls (20% [11/55] vs. 50% [27/54], p=0.001), measured by the Edinburgh Postpartum Depression Scale. No studies evaluated any other health outcomes or measured the effectiveness of RMC implementation strategies.

Conclusions. RMC frameworks with overlapping components, themes, and definitions were well described in the literature, but consensus around one operational definition is needed. Validated tools to measure RMC performed well based on psychometric measures but have been subject to limited evaluation. A reliable metric informed by a standard definition could lead to further evaluation and implementation in U.S. settings. Evidence is currently lacking on the effectiveness of strategies to implement RMC to improve any maternal or infant health outcome.

Cantor AG, Jungbauer RM, Skelly AC, Hart EL, Jorda K, Davis-O’Reilly C, Caughey AB, Tilden EL. Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture To Improve Equitable Maternal Healthcare Delivery and Outcomes. Comparative Effectiveness Review No. 269. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 75Q80120D00006.) AHRQ Publication No. 24-EHC009. Rockville, MD: Agency for Healthcare Research and Quality; January 2024. DOI: https://doi.org/10.23970/AHRQEPCCER269. Posted final reports are located on the Effective Health Care Program search page.