Introduction

Women in public and private sector maternity services in Africa have reported a wide range of physical and emotional abuse and neglect from health professionals (including midwives) in well-resourced and poorly-resourced settings [1–12] including in Zimbabwe [13]. The consequences of scolding and controlling approaches towards women in labour include poor obstetric outcomes such as delayed progress in labour, higher risk of instrumental and surgical interventions and postnatal depression, and are often unrecognised [14,15]. The dissonance between midwives’ professional pride and their apparently disrespectful behaviour in their workplaces creates tensions between them and the women in their care. Negative birth experiences may deter women from seeking institutional care during labour, whereas increasing rates of skilled birth attendance and facility-based childbirth are considered vital to reducing maternal morbidity and mortality [2,3,9,11,12].

A review of relevant literature, documents and interviews identified seven categories of disrespect and abuse in childbirth: physical abuse; non-consented care; non-confidential care; non-dignified care; discrimination based on specific patient attributes; and abandonment of care and detention in facilities [11]. These categories of abuse have been found from research in health facilities in African countries to be more widespread than anticipated, dispelling the notion that acts of abuse are isolated events carried out by “bad apple” individuals [1,2,4,5,8,11]. The failure of authorities to trigger disciplinary action in response to abusive activities has “normalised” such behavior especially in the eyes of health staff and is an indicator of health system weaknesses and failure of accountability [3,4,8,9]. The missing voices of midwives in research on abuse of women in childbirth has resulted in lower appreciation of the work constraints within which most midwives’ behaviour is embedded, which some argue constitutes disrespect for midwives themselves [15].

Research from African countries has shown that complex relationships between midwives and birthing women give rise to dissonance in the professional identity of midwives [8,9]. Midwives are expected as professionals to be altruistic, caring and to put the interests of women in their care first, but instead may demonstrate disrespectful behavior. They may purposefully use abuse to create social distance between themselves and birthing women, based on their perceptions of class, power, identity and knowledge superiority, as a protective strategy to avoid engagement and to preserve the power differential between them [8,9,16]. Professional ethics that champion women’s rights to information and autonomy could appear threatening to midwives in this context [8]. Medicalization of childbirth, with its emphasis on technology and pharmacological interventions, gives midwives control with rules and discipline over the experience of childbirth, rather than allowing women to have autonomy, to take positions they are comfortable in or by having companions to support them [6,15]. Some midwives who may be fearful of being blamed for poor outcomes, attempted to control women during childbirth, including by punishing them for disobedience with physical abuse [15,17]. This disrespect, neglect and abuse has been termed obstetric violence by some authors [14,17,18]. During institutional births, especially in low-resource settings, women may be left to give birth alone and are vulnerable without companions who could mediate for them and provide support [6,7]. Continuous practical and emotional support from birth companions during childbirth is associated with positive experiences and improved outcomes for pregnant women and their partners [14,19].

Abusive behaviour towards birthing women has mainly been studied using exit interviews and focus group discussions with service users and less commonly, with providers [1,2,10,11,15]. Various interventions have been proposed to motivate for more respectful behaviour. These include stronger nursing leadership, professional accountability, training to promote respect for patient autonomy, better adherence to codes of ethical practice, quality improvement initiatives, inclusion of birth companions and creating confidential complaints procedures that will not lead to patient victimization [1,7,8,11]. The legacies that have shaped health systems, the models of care and training, cultural norms within which they have developed, and the perspectives of midwives require greater scrutiny. Enabling midwives and pregnant women to develop greater agency and advocacy skills, despite being apparent victims of restrictive institutional cultures and health system failures, could lead to improvements of those systems [6,9,15].

The Respectful Maternity Care (RMC) Charter, which was developed in 2011 by a group of international stakeholders, promotes the rights of women receiving maternity services [20]. Key principles of RMC are freedom from harm and mistreatment, privacy and confidentiality, the right to dignity, to information and effective communication [20,21]. Compassion, the increased attention to the suffering of others with intention to assist them [22], is an important component of RMC. Interventions achieving RMC are expected to empower midwives and women in childbirth, giving both more agency and control in making decisions for themselves. For midwives this includes improved morale, greater professional pride and relatedness to each other. Building resilience, the ability of individuals to respond positively to adversity using effective coping strategies, is another component, based on midwives sharing social support and developing self-caring skills [23,24]. Education of midwives on the emotional and physiological aspects of labour, would expand their knowledge base to include understanding how scolding and shouting at women contributes to poor maternal and newborn outcomes [14,15,23]. However, education alone is insufficient to change attitudes and behavior and needs to be accompanied by a process of life-long learning that feeds into the construction of their professional identity as midwives.

Frenk et al (2010) have motivated principles of transformational learning (rather than informative or formative learning) as essential for strengthening health systems and improving quality of care [25]. The World Health Organization has also advocated more positive birth experiences [26]. Our interest was in how to put these concepts into practice. This qualitative study engages with the phenomenon of advancing RMC from the midwives’ perspective, to encourage sustainable behavior change, using methods grounded in promoting professionalism and rights of birthing women. The objective of the study was to assess changes in attitudes, behaviours and practices in a group of midwives in response to an educational intervention promoting RMC. Mezirow’s transformative learning theory [27–29] was used as a conceptual framework to explore the learning journey these midwives made in becoming “enlightened change agents” in relation to their work and for the birthing women they served. Critical self-reflection and challenge of core beliefs, assumptions and values, as a means of acquiring new knowledge by adult learners, are central elements of transformative learning theory. The ten phases of transformative learning [29] are listed in Table 1. Events of dilemma or dissonance are turned into opportunities for reflective inquiry, using for example dialogical learning within a group of midwives, to explore how they feel about incidents with women in their care [30,31]. Learners revisit their values and beliefs in relation to their new experience, questioning whether their worldview is accurate, to be changed or preserved. They discover new insights and self-awareness in relation to others. If learners change their views without questioning, or adopt new beliefs because of pressure on them, it will not be transformative [27].

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Table 1. Alignment of changes in midwives’ attitudes, behaviours and practices with the ten phases of Mezirow’s Transformative Learning Theory [29].

https://doi.org/10.1371/journal.pgph.0002008.t001

We chose to use reflective writing journals as a source of data on the experiences and learning of the midwives in this study. Diaries and journals often provide better data for research than interviews or observations, especially where the information being gathered is sensitive or revealing. They are less limited by recall bias since entries are contemporaneous [32,33]. Reflective narrative writing by health professionals is a skill that increases self-confidence in applying knowledge and skills, allowing them to critically assess the impact of their behaviour, which when connected with bearing witness to events of tragedy and wonder, may modify their behaviour towards more patient-centred care [23,31,34,35]. Collaborative reflective practice through journal writing and dialogue between midwives could lead to more nurturing relatedness with each other and women in their care. Their sense of self-efficacy and professional identity would derive from belonging to a community of practice, which awakens their sense of resilience. Communities of practice are networks of individuals who, through their interactions together, develop a common sense of identity, sharing knowledge, exchanging ideas, insights, values, stories, practices and expertise [36,37]. Revisiting core beliefs and values through this process would take midwives back to their understanding of what being a caring professional means. Critical reflection skills, self-awareness and effective life-long experiential learning are necessary for remaining competent as health professionals who are able to self-monitor and self-regulate [35,38].

Methodology

Findings

Analysis of the midwives’ experiences showed how changes in their attitudes, behaviour and practices aligned with transformative learning theory (summarized in Table 1) and arose through the learning process. The midwives started by describing in their journals, incidents at work which were challenging to them (“disorienting dilemmas”) such as women presenting with haemorrhage or sepsis following a backstreet abortion, a baby still-born, a woman screaming in pain, or a quarrel with an aggressive colleague. The midwives continued in their narratives, making sense of their experiences, confronting previous assumptions and learning through interpreting their discoveries and dialogues with each other as active participants. They gave examples where they had successfully applied new knowledge or understanding and how they felt about themselves as a result. The data from these journals and dialogues was coded into the following categories within the three domains of changes in attitudes, behaviour and practices.

Discussion

This study presents the voices of midwives, describing their lived experiences of caring for women during facility-based childbirth and how they changed through an educational process using transformative learning and critical reflection techniques. Although the study involved a small group of selected midwives, it yielded important insights into some of the underlying reasons for disrespect towards birthing women, with lessons for more effective midwifery training in low and middle-income countries (LMICs) and better-resourced settings. The midwives expressed gratitude to be heard. Their progression through transformative learning can be discerned from their reflections and discussions, as detailed in Table 1, starting with their descriptions of “disorienting dilemmas”, of incidents that occurred in their workplaces. These incidents exemplified the harrowing and stressful circumstances the midwives faced every day. Transition through the sequence of phases following those descriptions was not linear, although this is not considered essential for transformation to take place [27,43,44].

The midwives progressed from describing their verbal abuse and neglect of birthing women to self-identifying as agents of change and advocates for improved maternity care. The participatory and collaborative interventions in this study gave the midwives safe spaces in which to challenge their prior assumptions, such as that teenage mothers were irresponsible, or that women were lazy and would not progress in labour if they relaxed. They went on to make sense of their experiences based on their revisited values, beliefs and history, to explore and build new roles and responsibilities, and to reintegrate new ways of working into their practices. They collectively reimagined how they saw themselves as health professionals, what that meant in terms of attitudes and behaviour, the relationships they wanted with each other and the women they served. They became advocates for practices that were more women-centred, looked for solutions to the constraints they faced of space and time to enable women to move around in labour and to have companions, believing the scientific evidence that these led to better childbirth outcomes. They developed more compassion towards women in labour, and in the process became more compassionate towards themselves and each other. As part of self-care, they practiced breathing exercises, singing and stretching, to keep calm during times of stress, purposefully supported each other in reducing emotional exhaustion, and encouraged each other to smile more and be kind.

The perceived lower status of midwifery relative to that of obstetricians and medical doctors within the deeply hierarchical structures of health systems in many LMICs, contributes to lower self-efficacy, with the expertise and skills of midwives in childbirth unrecognized. In this study some midwives complained that they were treated as “handmaidens”, expected to only carry out instructions and not think for themselves, even though they are on the frontline of most maternity services. The RMC training encouraged the midwives to demonstrate higher autonomy in applying knowledge and skills to decision-making, alongside a stronger sense of competence and authority, and to benefit from greater relatedness to each other and birthing women. Becoming self-aware and patient-oriented, as manifestations of building competence and confidence in new roles and relationships, are key attributes of transformative learning. Midwives found the confidence and authority to encourage senior colleagues and doctors to behave more professionally, to respect their opinions and to be better team-players, negotiating better care for birthing women as their advocates, influencing the team culture to be more woman-centred. Aspects of professionalism in relation to midwifery have been less explored previously even though it is the foundation for RMC [15]. The collective construction of the midwives’ positive professional identity was a key outcome of this study where self-determination played a vital role in facilitating professional pride and resilience in the midwives [23,24]. Identity development is described as “interpreting oneself as a certain kind of person, presenting oneself as that person and being recognised as such in a given context” [45:e212]. Trying out new roles and having ones’ achievements recognised by others aligns with transformative learning and identity development.

Journal-writing and reflections were done individually, but exploration of their feelings, perceptions and behaviour change occurred through group-work during the follow-up sessions, as they established and reinforced in each other new ways of viewing the world and understanding each other. They continued as a community of practice after the RMC training concluded, supporting each other in being more open, inclusive, reflective and emotionally able to change. The midwives spoke with pride of their roles and responsibilities as professional midwives, of the negotiation and conflict resolution skills they developed through the RMC training and through their own teambuilding during the year, as well as sustaining many of the changes they made in their practices. Their identities now included themselves as champions and change agents, actively promoting attainment of human rights for women in terms of RMC.

Using a human rights approach to maternal health, including promotion of the RMC Charter [20], created a light bulb moment of realization and inspiration for the midwives, that women had the right to dignity, privacy, information, freedom from harm, to have companions, to choose their positions for giving birth. This revelation acted to put midwives on a more equal footing with women in labour, to reduce the social distance between them and to engage with them as adults. The midwives learnt through their reflections and dialogues what lectures on professionalism could not have achieved. They revisited their assumptions with new perspectives, reversing their approaches towards women with difficulties, understanding more what they were going through by listening to them, instead of distancing from them or abusing them [15,16]. They learnt that resistance from birthing women was often because of fear of the unknown, of pain and danger. These changes were dramatically witnessed with younger unmarried women, for whom negative attitudes of health workers often act as barriers to good sexual health [46]. as though their misfortunes are deserved as punishment for breaking the rules. The change towards greater compassion in the midwives’ responses, giving advice and encouraging further care and support, meant that these young women were more likely to have better reproductive health in future. In treating birthing women with respect, providing information so that they also had choices and autonomy, listening more to what their needs were and acting on them, the midwives demonstrated greater respect and compassion for themselves and each other. The appreciative feedback they received from birthing women and colleagues reinforced their sense of professionalism, competence and relatedness, as did the support they received from senior health professionals and managers. Focusing on what went well rather than only what went wrong, helped to boost morale and provided ideas of what could be done better.

Although failures in maternal health services underlay many of the stresses faced by the midwives, they took ownership of the small incremental changes they could make to improve women’s birthing experiences, despite the long hours they worked in difficult conditions. They focused on their immediate relationship with women in labour rather than being defeated by the social and economic difficulties faced by the women they served. The midwives’ narratives revealed how they overcame their loss of morale, helplessness and shame by seeing themselves as change agents and RMC champions. This observation provides an alternative perspective to the suggestion that training midwives to manage their constraints more effectively burdens them with the responsibility to cope, rather than challenging the health system for its deficiencies [15]. Many public sector health facilities in less-resourced environments struggle to improve quality of care in the face of workforce shortages and burn-out, inadequate facilities and lack of equipment. Advocacy to address such health system weaknesses must continue alongside ways to use existing resources more effectively. Many of the interventions proposed within RMC can be carried out with minimal financial inputs, or with adaptations of existing equipment and space, but have been shown to have considerable impact on staff morale and enthusiasm, and patient satisfaction. Encouraging birth companions and use of alternative birthing positions may need more space especially in busy labour wards, but the midwives, in their mindsets as change agents, looked for solutions “outside the box” and campaigned for these with their managers.

A concern of moving from research to action is whether the changes achieved would be sustained outside of the study environment without the resources and influences that usually accompany research. The challenge is whether the midwives changed sufficiently to practice RMC without the workshops and continuing facilitation. Learning experiences are said to be transformative when the changes claimed persist and endure, when they are not limited to behaviours but to a way of seeing the world, being more open-minded, inclusive and having deeper self-awareness [43,47,48]. They are then likely to be relevant and connected across learning (integrative) and unlikely to be forgotten (irreversible) [16]. Whether the changes described by the midwives in this study are truly irreversible and integrative will only be seen through future reviews of their work. Similar methodologies of guided reflective writing and facilitated follow-up discussions would be required for new learners with the RMC champion midwives trained as facilitators and mentors. Health professionals need safe spaces to express themselves, to interact and to develop agency in addressing hierarchical issues present between them, and between them and the people they serve [34]. The RMC workshops created dedicated spaces, away from each person’s workplace, where the midwives felt free to take part in critical reflection, even exposing their earlier weaknesses. Whether such training can be replicated within workplaces where this freedom may not be available needs further research.

To measure impact of the midwives’ behaviour and practices in improving health outcomes will need alternative study designs, such as patient satisfaction surveys, monitoring indicators of quality of care and quality improvement studies. At present, it seems that peer support and approval from managers is sustaining these midwives in their new roles as change agents, especially in their team meetings. The focus of this paper has been on the narratives of the midwives, foregrounding their perceptions and experiences, emphasising the value of innovative training methods. We recognise however that the structural and policy related issues that influence the spaces within which the midwives work and the power dynamics that are at play in these spaces, have not gone away. Further research is needed to show how RMC can be embedded and sustained in organizational and team cultures, in flattening professional hierarchies operating in maternity services and promoting interprofessional collaboration, how health policies and payment systems can be used to improve the working environment for maternity teams [17,18]. Research is also needed on how civil society organisations, advocacy groups and professional associations can hold health services, governments, and policy-makers to account for inadequate maternity care and poor birth outcomes also [49].

The features of this study using transformative learning theory to support midwives in becoming meaningful RMC change agents were: professionalism and agency; being women-centred and responsive to needs; use of scientific knowledge to inform practice; critical reflective reasoning skills; non-hierarchical relationships and effective team-work; collaborative decision-making; communication skills; local resource mobilization and sharing. The challenge is whether it is only through this intensive process of transformative learning that RMC approaches can be instilled in midwifery training. There are models of training that have incorporated RMC and these educational methods into midwifery curricula. Educational tools have been proposed to facilitate reflective skills in midwifery students [50], to integrate theoretical knowledge with practice and learning from powerful experiences and interactions underlying observable activities in work [35,51]. Skilled facilitation by educators is essential to support learners in situations that may be distressing or uncertain, offering dilemmas to learners to provoke curiosity and exchange of perspectives, highlighting the complexities and ambiguities learners have to respond to [30,31,34]. At least one midwifery training programme in Zimbabwe has included RMC into its curriculum using these methods (P Mataure, personal communication). Short courses and workshops encouraging flexibility in birthing positions and involvement of birth companions have been held in other hospitals. A toolkit based on our workshop materials has been produced by this team for use as training aides, which has been shared widely. Future research will reveal how effective these methods have been.

Conclusion

The educational intervention at the centre of this study was different from conventional midwifery training. It was centered in self-reflection and dialogue, reframing key assumptions and progressing to self-awareness and confidence, positive professional identities, with greater compassion for women in labour and enhanced relatedness with colleagues. Lectures and didactic information dissemination are unlikely to have the same impact. The midwives acquired skills that enabled them to continue their reflective exercises, incorporating lessons from these into team-building, weekly feedback meetings and advocacy for resources. Collective imagining, dialogue and action are vital components of this method, with authentic engagement, support during times of stress and disillusion, shared experiences and knowledge, leading to motivation for change (30). This learning method is resource-intensive and requires considerable commitment from learners and facilitators. This study explores what is needed for sustained changes in attitudes, behaviour and practices in a group of midwives. It also demonstrates the power of narratives in understanding their interaction with the health system. With the ultimate goal of improving quality of care, health outcomes and birth experiences for women, the study suggests ways of achieving meaningful culture changes in midwifery training in sustainable and enduring ways, using innovative methods of promoting effective group working, skills for relationship building, and support networks to carry them through the tough times to the rewards and benefits that follow.

Acknowledgments

This paper is based on a research report submitted by SR as part fulfilment for her MPhil HPE, Centre for Health Professions Education, Stellenbosch University, South Africa.

The authors give thanks to the White Ribbon Alliance for Safe Motherhood Zimbabwe andWomen’s University Zimbabwe for their partnership with the workshops and production of the toolkits; to the midwives who participated in the educational intervention and study, to the Ministry of Health & Child Care, Sally Mugabe Central Hospital and the private maternity services for permission to conduct this study; and to Vicky Owens and Sarah Fox, midwives from Swansea Bay University Health Board Wales, for facilitation during the workshops.