Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Figures & data

Table 1. Description of important concepts

Concepts	Description*
Complex adaptive system	A type of system which comprises diverse agents (complex), and where the behaviour of each agent is responsive to the interactions with other agents within the system (adaptive)
Self-organisation	The way in which agents interact to coordinate their own forms, or patterns of behaviour arising from repeated agent interactions over time
Nonlinearity	The heterogeneous and multiple levels of interaction between agents which makes agent response unpredictable
Feedback loop	Recursive mechanisms as a result of multiple agent interactions over time that create reciprocal behaviour either reinforcing (positive feedback loop) or undermining (negative feedback loop) each other
Emergence	New system behaviours (larger entities) generated by the interactions of smaller or simpler entities
Path Dependence	Past experiences influence the responses to new events
System hardware	Constituent of health system that includes human resources, financing, technology, service delivery, infrastructure, and supplies
System software	Constituent of health system that includes tangible (leadership, management, and governance knowledge and skills, rules and procedures) and intangible (values and norms, power relationships, and information communication) elements that interplay with system hardware elements to influence the system

*Source: Modified from Braithwaite et al.³²; Gear et al.²⁶; Gomersall et al.²³; and Sheikh et al.³³.

Table 2. Profiles of study hospitals

Characteristics	Hospital I	Hospital II	Hospital III
Geographical and population profile (2017)
Location (urban/rural)	Urban	Semi-urban	Semi-urban
Catchment population	359,358	261,271	267,589
Expected pregnancies in the catchment	12,434	9,040	9,259
Number of public hospitals in the catchment (including current one)	03	01	01
Number of health centres in the catchment	05	09	11
Facility profile
Total number of births attended in the last quarter of 2017	1081	433	713
Total number (%) of caesarean births in the last quarter of 2017	164 (14.9)	62 (14.3)	138 (19.4)
Upgraded from a lower-level facility (Yes/No)	Yes	Yes	No
Number of labour wards	02	01	01
Total number of beds in the labour ward	10 (5 in each)	05	05
Number of delivery rooms	01	01	01
Total number of birthing beds in the delivery room	04	04	3
Type of delivery room (Partitioned/Non-partitioned)*	Non-partitioned	Non-partitioned	Non-partitioned
Number of functional showers in the labour ward	0	02	01
Number of functional handwash basins in the labour ward	01	02	01
Designated waiting area for accompanying family members (Yes/No)	Yes	Yes	Yes

*Open plan with multiple beds per room with no curtains/partitions.

Table 3. Description of the RMC intervention

Component	Description	Participants	Intervention period
RMC training	The RMC training manual included contents on an overview of maternal health in Ethiopia; human rights and law in the context of reproductive health; RMC rights and standards; professional ethics; and continuous quality improvement. The manual was designed after a thorough review of RMC implementation programmes in Kenya, Tanzania, and Nigeria; and WHO’s recommendations of Intrapartum Care for Positive Childbirth Experience; and national guidelines and professional ethics codes.	64 service providers at the participating hospitals who assist women during childbirth (in two rounds)	First round: 25–27 April 2018 Second round: 2–4 May 2018
Wall posters	Four wall posters The universal rights of childbearing women prepared by the White Ribbon Alliance (one poster) Infographics taken from the intrapartum care for a positive childbirth experience guideline prepared by the WHO (three posters)	All (64) training participants The wall posters were included in the RMC training manual and all participants were briefed on these.	25 April–4 May 2018 Posters were handed over to the hospitals’ MCH coordinators at the end of the second round training session.
Onsite supportive supervision	Two rounds of post-training quality improvement supportive supervision were conducted to appraise the action plan implementation, and to set actions for the next cycle with the long-term aim of developing a culture of continuous quality improvement actions. Guidance on a facility-led assessment of RMC using a structured checklist that was part of the RMC training manual. Guidance on action plan development to address actionable gaps identified by the assessment checklist.	All (64) service providers who attended the RMC training. (There were service providers who attended both rounds of the supervision.)	First round: June 2018 Second round: July 2018

Table 4. Summary of participants and topic areas investigated during FGDs and IDIs

Category	Facility	No. of FGDs/IDIs	Total no. of participants*	Topic areas explored
Pre-intervention FGDs	Hospital I	2	16 (14 midwives, 2 nurses)	Features of quality maternity care; twice and perception of mistreatment; twice and perception of respectful care; contributors to mistreatment; challenges experienced in labour wards; motivators and demotivators to provide respectful care; actions required to promote respectful care
	Hospital II	1	8 (7 midwives, 1 integrated emergency surgical officer)
	Hospital III	1	8 (7 midwives, 1 health officer)
Post-intervention FGDs	Hospital I	1	7 (6 midwives, 1 nurse)	Perceived behavioural influences of the training; challenges encountered, and new behaviours emerged in implementing the training; additional actions required to implement the training; partakers of RMC
	Hospital II	1	8 (8 midwives)
	Hospital III	1	6 (5 midwives, 1 general practitioner)
Pre-intervention IDIs	Hospital I	4	4 (MCH** coordinator, quality focal person, medical director, and chief executive officer)	Features of quality maternity care; twice and perception of mistreatment; twice and perception of respectful care; contributors to mistreatment; perceived status of respectful care; respectful care initiatives; challenges in advancing respectful care
	Hospital II	4	4 (MCH coordinator, quality focal person, medical director, and chief executive officer)
	Hospital III	3	3 (MCH coordinator, quality focal person, and medical director)
	Regional health bureau	1	1 (senior maternal health expert)

*Most FGD participants were midwives because 80% of service providers who assist women during childbirth in the study hospitals were midwives.

**MCH: Maternal and child health.

Figure 1. Causal loop diagram of factors influencing respectful maternity care in hospitals*

Notes: “+” sign on the blue arrows indicates the causing variable increases the outcome variable. “−” sign on the blue arrows indicates the causing variable reduces the outcome variable. “R” in the red rotating arrows indicates the variables have a reinforcing effect on each other in the direction of the arrow.

Braithwaite J, Churruca K, Long JC, et al. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med. 2018;16(1):63.

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Sheikh K, Gilson L, Agyepong IA, et al. Building the field of health policy and systems research: framing the questions. PLoS Med. 2011;8(8):e1001073.

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