4D stages of AI and interview guide.

The defining stage of Appreciative Inquiry (AI) involves addressing and clarifying the topic of inquiry and ensuring it has a positive core[28]. Cooperrider and colleagues argue that understanding the positive core is vital when using the AI approach, emphasizing choosing affirmative topics that genuinely reflect what people want to explore or learn more about [28]. These topics focus on the positive moments and envision possibilities for a better future. The positive core is integral in all AI phases, highlighting and magnifying what gives the organization life [18,28,35]. In this phase of this study, the author defined the topic of inquiry focused on exploring the best moments of RMC and the perceptions of mothers recently delivered in Eastern Rwanda’s maternity facilities.

The discovery phase consists of identifying and appreciating existing positive aspects by exploring what works well. Questions that we posed centred around "What gives life?" or "The best of what is" to gather positive stories from participants. This phase aims to unveil the strengths and positive elements [18,28,36]. The discovery phase in AI involves identifying and appreciating the best aspects of experiences[18,28,36]. AI’s unique feature is its positive framing of questions, focusing on peak moments of excellence[28,36]. The participants share stories of exceptional valued accomplishments, emphasizing core life-giving factors. Throughout the discovery phase, AI creates a supportive context for dialogue by maintaining a consistently positive orientation [28,36]. In the discovery stage, participants share their experiences, particularly their best moments [28,36].

In this study, we asked the mothers to reflect on their experiences and share their best moments of RMC/ their greatest experiences of recent labour and childbirth in the hospital. The specific question posed to the mothers was: "What is the best RMC experience that you have encountered during your labour and childbirth in the hospital?" "At any point during labour and childbirth for this childbirth, tell me any other kind of treatment that made you feel good/dignified or respected? "What is the care were you happy with or loved the most during labour and childbirth?" "Why did you like that?" The research team ended up identifying the vital themes from the stories together.

The dream phase consists of envisioning the overall vision, results, and impacts, as well as fostering innovation by asking questions like "What might be?" [28,29] This phase involves using the insights from the discovery phase to create a set of aspiration statements, guiding the design of future actions. Participants identify new possibilities for the future[5,35]. The dream phase envisions a positive future, building on qualities discovered in the Discovery phase[35]. AI grounds future images in the positive past, creating compelling possibilities from extraordinary moments [28]. The primary goals are fostering participants’ dialogue by sharing positive stories and identifying common themes without critique [29,36]. AI does not focus on solving problems but emphasizes mutual discovery, guiding participants to envision an organization that embodies their hopes and dreams[5,35].In the dream stage, participants describe their dreams and desires and envision the possibilities of what could be considering their own needs and preferences [28,29]. The mothers and HCPs were asked to foresee and picture RMC for the future. In this phase, the study participants (mothers and HCPs) recommended sustaining and promoting the best-reported RMC practices.

In this study, the participants were encouraged to share their aspirations for RMC during their labour and birth process in the hospital. They were asked to think broadly and holistically about the future they desired. The specific question posed to the participants was: "What would be the best RMC for you during your labour and birth process in the hospital? How do you wish it was?" "What do you think has made possible for your care to be good?"

The design stage generates implementation options and co-constructs plans by focusing on the following: "What should be the ideal?"[5,29]. This phase aims to identify concrete actions to support the new possibilities envisioned in the dream phase[18,28]. Participants collaboratively create and commit to actions that will turn aspiration statements into reality [28,29]. The design phase articulates the strategic focus, including a vision of sustainability and a compelling statement of strategic intent[18]. The design stage gathers valuable insights from the participants to inform the development of practical steps and interventions that can enhance RMC within the hospital setting [29], focusing on recommending and developing strategies to sustain RMC within the hospital setting.

In this study, the mothers were asked to provide recommendations and suggestions to envision and portray an improved RMC for the future. The specific question posed to the mothers was: "How should RMC be improved to contribute towards creating an RMC hospital environment?" "What can be recommended and developed to ensure the sustainability of RMC in the hospital?"

1. Appreciated care.

Participants reported receiving compassionate care, free from mistreatment and violence. They expressed that their choices and preferences were respected throughout their recent childbirth experiences. They also reported receiving dignified and equal care, being attended to in a timely manner, and receiving the necessary services; their privacy and confidentiality were respected, and they received adequate information regarding their health status and care.

Compassionate care and emotional support. The participants expressed examples of feeling treated with empathy and compassion. These included: receiving anaesthesia before suturing vaginal tears and episiotomy, being provided with painkillers after caesarean birth, and being offered support to manage labour pain. Participants who gave birth by caesarean section were systematically provided with painkillers after childbirth. Those who experienced pain during normal childbirth were comforted; however, they were also aware that pain is a natural part of the childbirth process and that there were no specific interventions to reduce pain. Mothers expressed that although they had to endure the pain, HCPs should address all of a mother’s concerns during childbirth.

"I don’t know how I can describe that care I received here; it’s too much. After the operation, they start giving me perfusion and giving me pills to reduce pain…"It is the first time I gave birth; the first thing that ever causes pain is labour. However, when someone cares about you and ensures you that labour will progress like that or that, you feel energized." Participant 12, aged 28 years, gravida 1, C/s childbirth

"I heard that pain is necessary; you have to suffer and get well… our parents tell us that you have to suffer, but you will be fine…Because there is nothing to reduce the pain, they (HCPs) are saying be patient; you will get better." Participant 26, aged 22, gravida 1, normal childbirth

Mothers appreciated the dignified care they received and consistently said that they felt happy and satisfied with the services they received. The HCPs were patient with the mothers and spoke to them with comforting words, kindness, and politeness. The mothers explained that they had not been harassed in any way, that the HCPs answered their questions without rudeness, and used gentle and soft expressions when interacting with them. Mothers were grateful because they felt valued and that the birth attendant had stayed close to them throughout the process. It meant a lot when the birth attendant praised them for pushing the baby out because it gave the courage. The mothers described the staff as lovable due to their kindness and caring attitude.

"In healthcare providers, there was a lady who told me ", mama, push, be patient, be patient darling, push; the contraction is in. I felt happy"… the midwife comforted me and told me: ’all the tears you cried, I want to wipe them away’…. Now I am satisfied, I don’t know how I can say it, but it made me very happy" Participant 17, aged 26 years, gravida 2, normal childbirth.

Autonomy and Self-determination. Mothers reported feeling freedom during their childbirth experiences. They were not restricted from praying and were allowed to eat and drink; they had the freedom to walk, although within a limited space. The participants received equal treatment, there was no favouritism, and the hospital assisted those in need, such as providing diapers for the baby. Mothers further stated that their choices and preferences were respected and felt supported by the HCPs. Mothers who came without a transfer letter were also received with kindness, and the participants were not denied any service and received assistance every time.

"I told them my choice for family planning, and they immediately did it to me. I told them that I had decided to use the sterilization, and I had to talk to the doctor in charge, and he did it for me." Participant 28, aged 40, gravida 8, normal childbirth

Mothers reported that they received guidance on how to behave well during their childbirth experiences, including being advised on precautions to take and practising self-control. They expressed happiness at being shown the placenta and receiving information about family planning and birth spacing. Some mothers were taught breastfeeding techniques and were encouraged to have regular meals to ensure an adequate milk supply. Additionally, some mothers were informed about the progress of their labour and encouraged to stay hydrated by taking fluids.

"Every time I needed the doctor, he came and told me that you are on this point, you are going to give birth well, relax. When I needed him again, I called him until I gave birth, and he assisted me well, comforting me, telling me to push, and do it quickly without being rude to me but with kindness". Participant 21, aged 21 years, gravida 2, vaginal childbirth

Mothers were happy simply because they were not being coerced, and they expected that consent would not happen. They were informed and requested to provide informed consent, especially those who experienced caesarean section.

"Doctor always asked me " Would you come for a check-up to see your labour progress? Would you come for an ultrasound to check if the baby is still alive? and I said yes. They told me that I am going to have surgery, they told me that you have to sign and your companion needs to sign too; once you have signed, you have agreed to the surgery they are going to do for you". Participant 13, aged 28, gravida 1, C/s childbirth.

However, most participants were not explicitly asked for verbal consent during routine examinations. Mothers reported that they did not feel the need to be asked for permission as they trusted the expertise and abilities of the HCP. Mothers believed that it was their responsibility to follow the instructions given by the HCP. Nonetheless, participants expressed satisfaction with the practice of negotiation instead of coercion.

"When they take you to the examination bed, you are already aware that they are going to examine you…. well, when we are there, there is no need for permission because the doctors do what they were taught, or they were appointed for. Whatever they do, you feel it is right… Listen, because of pain, you don’t have to argue; you even think the service provider is the one to recover you." Participant 18, aged 23 years, gravida 2, vaginal childbirth.

Timely care provision. Most of the mothers expressed happiness and were impressed by the care received. They reported receiving the best services and all the necessary care. The HCP attended to them promptly and assisted them every time, even when they were working overtime. In some hospitals, they first use available medicines, and mothers reimburse them later. The entire process was well organized, and mothers who arrived in critical conditions were given hope and excellent care. When the HCPs could not manage a case, they called experts for assistance. One notable example was when a very experienced midwife successfully helped a mother deliver vaginally despite indications for a caesarean section.

"The midwife gave me the best possible care. He was a good-hearted person, and I feel very happy. I was so happy with what they did to me that I felt like giving her a car; poor me, I don’t have it.… Whenever I wanted the doctor, he came to me every time I called him, and he did not complain no matter how much I disturbed him" Participant 21, aged 21 years, gravida 2, vaginal childbirth.

"The thing that made me happy was that I had weak contractions the whole day, and they gave me a pill to boost them, and I got strong contractions. They also did an ultrasound and told me that the baby was in a good position, and I would give birth without any problem." Participant 10, aged 22, gravida 1, vaginal childbirth

Privacy/Confidentiality preservation. The participants described privacy as an important part of feeling well cared for. Privacy was ensured as described by the mothers. They reported that they were not exposed to the public during the childbirth process, and curtains or doors were closed to maintain their privacy. Mothers were allowed to be alone with the HCP, and cleaners were not allowed to enter the room during their stay.

"I am thankful that these cleaners cleaned after you gave birth; no one ever saw me. In the childbirth ward, there are large curtains. Even the cleaner who brought the materials, the doctor took them without letting her in…. When a person wanted something, the service provider went out and opened the curtains to listen to what he needed. " Participant 5, aged 27, gravida 2, vaginal childbirth.

To ensure confidentiality, healthcare providers spoke quietly to the mothers. However, mothers reported that they could hear other mothers’ health information. Nevertheless, mothers revealed that it did not matter to them, as they shared suffering from labour pain.

"Even though sometimes, we are many here, I can hear the health information of my peers and vice versa, but since you are all suffering, it doesn’t matter…it would not matter because a other women in the hospital can’t share my information knowing how herself she was doing in labour and the way we shared sorrow of labour pain." Participant 18, aged 23 years, gravida 2, vaginal childbirth.

Enabling environment. Some women were excited to give birth in a large building (on an upper floor). However, mothers reported that the birth companions were not allowed to stay with them in the waiting room, particularly in the childbirth rooms, due to the structure of maternity rooms. However, most participants believe that birth companions are not helpful during the second stage of labour and that only HCPs are of assistance. In the Rwandan context, the birth companions are actually family members such as the mother of the woman, her mother-in-law, sisters or friends. The participants narrated that birth companions are not health professionals and can become scared and discourage the mother. Participants also reported that birth companions are often busy buying medicines or doing other outside tasks. They suggested they should simply stay nearby and be available to bring the baby’s clothes after birth.

"The birth companion could not be of help; she wasn’t a doctor to examine me; she was only responsible for standing there near the door and waiting for them to say that I gave birth and brought the baby’s and mother’s clothes. I would not want my birth companion to come in! because even now, birth companions can see how you are doing and get scared and say that you are dying, but a healthcare provider, even if you are going to die, keeps telling you to be patient." Participant 26, aged 22, gravida 1, normal childbirth.

Some mothers expressed satisfaction with the overall hygiene and cleanliness of the hospital. Cleaned toilets and regularly changed bedsheets made them feel satisfied. HCP often requests the cleaners to clean rooms multiple times. However, while some mothers were pleased with hygiene, others complained that the cleanliness in the toilets was insufficient.

"I am also happy that the hospital is clean, you sleep, and they take care of your sheets and change them for you, and the shower and toilet are all clean without any problems. There was no problem, and the cleanliness was satisfying." Participant 28, aged 40 years, gravida 8, vaginal childbirth.

2. Perceived respectful care.

Participants expressed their understanding of respect during labour and delineated the elements that contributed to their contentment with the services provided.

Meaning of respectful care. Most participants understand that RMC encompasses privacy, confidentiality, and freedom of movement during labour. They associate RMC with receiving timely and compassionate care, being spoken to in a soft and compassionate tone, being spoken kindly and politely, comforting her, actively listening, and staying close to her. RMC is seen as attending to the mother promptly, starting with those in critical condition. It involves receiving the mother well, showing patience, and inquiring about her well-being and that of her baby rather than abandoning, harassing, ignoring, or silencing her.

"The respect is when health service does not expose you in public if you arrive at the hospital, you are cared for, when a service provider comforts you by saying, sorry mom, sorry darling, with a smiling face, that is good…. When you are in the room, you are in a private place; you are private if there is a door, they put on a curtain or close it, and you feel that you are alone with a healthcare provider, and you feel you are respected." Participant 17, aged 26 years, gravida 2, normal childbirth.

"I feel that respecting a mother means being there when she needs you. You should make her feel comfortable and free to express herself. A mother should be allowed to move around during labour because it helps her feel better." Participant 21, aged 26 years, gravida 2, normal childbirth.

Mothers perceive professionalism as a crucial factor in providing RMC. They value love, compassion, and a sense of being valued by HCPs as important facilitators of RMC provision.

"What makes service providers give me good care is the love and compassion healthcare providers have or that they value their duty. Maybe I had met doctors who knew what they wanted to do or who valued their work ". Participant 18, aged 23 years, gravida 2, vaginal delivery.

Happiness motives. Mothers expressed that fulfilling their desires was the most important reason for appreciating and feeling proud of the services they received. Their primary wish and expectation were to have a normal childbirth and a healthy baby while maintaining their own health. Additionally, mothers reported negative anticipatory feelings when seeking maternity care. However, HCPs were available round the clock, closely monitoring and encouraging them and instilling hope. Mothers appreciated that HCPs were not preoccupied with phones, treated them with respect, offered comfort and support, and showed genuine concern for their well-being. One mother even expressed happiness at reuniting with a midwife who had assisted her in a previous childbirth fifteen years ago. The perceived drivers of RMC, as reported by the mothers, included displaying love and professionalism, having a sense of responsibility, valuing both the work, receiving appropriate training, and the mother’s critical state. The moment of getting their newborn baby was described as a transformative experience, overshadowing the pain of labour.

"It was truly great. The doctor was telling me to relax and not worry; there was no other reason; service providers told me that I wanted to have a healthy baby because the doctor told me, "I will help you to give birth well. I did not have surgery. The thing that I am happiest about is that I saw a healthy child. For me, the first thing that makes me happy is to see a healthy child." Participant 11, aged 28 years, gravida 3, normal childbirth.

Remarkably, one participant who had experienced the loss of their baby due to severe prematurity expressed appreciation for the services received.

"From when I arrived until I left down there, up to now, healthcare providers took good care of me though my baby passed away. If I were able to reward them, I would do it; I would repay them if I had something. They took care of me". Participant 24, aged 20, gravida 1, C/s childbirth.

Very few participants had positive expectations, such as hoping for a quick delivery or expecting to receive an ultrasound examination. Since most of the mothers were referred, some also anticipated a smooth and uncomplicated childbirth, and all of these expectations were fulfilled.

"I saw that my baby was still alive in the womb…They just showed me her and told me she is a girl and ensured me that she is healthy; that makes me happy". Participant 13, aged 28 years, gravida 1, C/s childbirth.

Participants generally reported low expectations when seeking maternity healthcare due to the information received from their communities. Mothers expressed concerns upon going to the hospital for childbirth, having heard negative stories from others and anticipating potential insults and physical mistreatment. Some were unaware of the current procedures and expected to receive the same treatment as in previous years. They anticipated being physically abused, insulted, scolded, subjected to fundal pressure, or unnecessarily undergoing a caesarean section. They also expected to be exposed naked in public and rudely spoken. They came with the fear of dying, being provoked, ignored, and being required to pay before receiving any service. However, participants experienced positive experiences.

"I was thinking that I get here and give birth by insulting me; they don’t hit me as I have been told. Before coming here, I have been told that some are beaten; I thank God they did not beat me. I found it different; I’ve met a kind doctor… And the fact that I arrived here, they cared for me, they did not beat me, and then I gave birth immediately, that’s made me happy". Participant 16, aged 19 years, gravida 1, vaginal childbirth.

3. Suggested strategies.

To sustain RMC, mothers provided recommendations to service users, caregivers, and hospital management. Each level has its own responsibilities to fulfil.

Mother Self-control. Mothers reported that they have a responsibility to respect HCPs by following the instructions given by HCPs, using family planning to space their births and regain confidence. To ensure the lifelong sustainability of RMC, they wish that their children would attend school and become future HCPs dedicated to providing quality services.

"Mothers should respect health care providers too; we should have few children. You know, mothers, we always give birth, and you find that it is stressful, and we have to plan for the family". Participant 30, aged 29 years, gravida 3, vaginal childbirth.

Provider behaviours. Respondents advised the service providers to sustain their courtesy, respect, and love towards the mothers. They should ensure the mothers’ comfort and feel responsible in providing maternity care, providing guidance to the mothers and maintaining the existing culture of timely care, mutual understanding, and respect. The mothers advised the providers to re-evaluate themselves, work diligently, and care for the mother as a human being. The mothers recommended that doctors respect subordinates, such as cleaners, and cooperate with midwives, nurses, and mothers.

Mothers requested HCPs to prescribe affordable medicine and avoid unnecessary prescriptions of surplus medical supplies. Providers should explain the progress of labour and communicate the results of examinations to the mother. It was suggested that HCPs talk with the mother while providing care, explain the labour process and progress, and assist mothers in having a normal childbirth as much as possible. Additionally, it was advised that HCPs prioritize triage and handle emergency cases quickly. Mocking multigravida women and unnecessarily retaining mothers in the hospital were discouraged. Security personnel at the gate were also advised to be briefed on respecting and allowing mothers to enter the hospital.

"Doctors should take care of patients as if it is their responsibility, not because it is their job, but because it is their responsibility". Participant 11, aged 28 years, gravida 3, normal childbirth.

HCPs should strive to understand each other and avoid quarrels between them. One mother reported hearing HCPs insulting one another, while other HCPs complained about working overtime. Mothers advised that such behaviour should be stopped, as the consequences could ultimately affect the service users.

"There is a time a healthcare provider come and found her fellow did not fill the form accurately then insulted her… I hate insulting …. some healthcare providers were complaining that there are some who work days and nights, saying a lot of things like, "Why didn’t you give me my off time?" Healthcare providers came saying, "I am fed up with this. I may leave this job. Look, I did a day shift, and I did not take a break. They want me to fill out these while my working hours were finished."…, if a health care provider claimed to her colleague that she is tired, you could listen to her". Participant 24, aged 20 years, gravida 1, C/s childbirth.

Caring leadership. Mothers recommended that the hospital leadership train, supervise, and innovate ways to motivate the HCPs. Participants emphasized the importance of publicly showing gratitude to the HCP and ensuring timely payment of salaries. Increasing the number of HCPs and providing sufficient labour monitoring equipment are suggested. Mothers also highlighted the need for continuous training for HCPs, including new graduates and students, and providing mentorship to ensure the childbirth of quality care. They recommended that future HCPs be taught to prioritize patient care and love for their patients. Conducting campaigns and workshops on RMC was seen as beneficial. Another important suggestion was to build or renovate hospitals with spacious rooms and an adequate number of beds to avoid mothers and newborns sharing beds. Last, they emphasized the importance of striving to have a good reputation in the community.

"Doctors leaders would come to their colleagues and perhaps thank them and tell them that maybe all mothers who gave birth in this certain time are happy, and I think it will motivate them to continue doing well". Participant 15, aged 32 years, gravida 3, vaginal delivery.

Some respondents recommended that the hospital provide food to mothers whenever possible, especially for those who come from a distance and may not have money to buy food from the canteen. Regarding hospital bill payments, it was suggested that priority should be given to providing care to the mother first, with payment arrangements made afterwards. They also recommended that the cost of services should be proportionate to the service received and that prescribed medications should be covered by health insurance. Respondents suggested that the hospital and the mother could enter into a contract allowing for gradual payment to address the issue of mothers being retained in the hospital due to an inability to pay. Participants emphasized the need to improve hygiene and cleanliness in the hospital environment. Regarding personal hygiene, some mothers expressed resistance to using diapers during labour, fearing harm to their babies. Mothers also raised concerns about hospital overcrowding, where two mothers may have to share one bed.

"Another thing is that they should add hygiene and cleanliness, and they should clean properly so that mothers will not acquire illness." Participant 16, aged 28 years, gravida 3, normal chilbrith.