Introduction

Respectful maternity care (RMC) is a universal human right of all pregnant women [1]. RMC is “the care organized for and provided to all women in a manner that maintains their dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth” [2]. The accessibility of RMC is fundamental to promoting care-seeking behaviour and ultimately ensuring the health and well-being of mothers and their newborns. The disrespectful and abusive behaviour of care providers has been identified as one of the barriers to seeking care [3].

Seven key areas of disrespect and abuse in childbirth were defined by a landscape analysis carried out in 2010 as: “physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination based on specific patient attributes, abandonment of care, and detention in facilities” [4]. From a systematic review conducted in 2015, a comprehensive classification of the mistreatment of women during childbirth was established which comprises “physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints” [5]. Despite several interventions aiming to address the problem, disrespect and abuse of women during childbirth is prevalent worldwide [6]. As per the findings of studies conducted in numerous countries, 22%−100% women have reported at least one type of disrespect and abuse during facility-based births (Northern Ethiopia: 22%, Southwest Ethiopia: 91.7%, Pakistan: 97.7%, southeastern Nigeria: 98%, central Ethiopia and Eastern Nepal:100%) [7–12].

Scholars highlight the importance of moving beyond the mere measurement of the prevalence of disrespect and abuse to focus on mechanisms that strengthen accountability for RMC [13]. Evidence from a systematic review indicated that interventions designed to promote RMC are essential for improving the overall quality of maternal health services, with positive outcomes reported in Tanzania and Kenya following such initiatives [14]. Another review, which synthesized findings primarily from six sub-Saharan African countries, further demonstrated that multi-component interventions were particularly effective in reducing mistreatment and fostering RMC [15]. Women cared for by providers who had received training in compassionate and respectful care were more likely to report RMC [16,17]. Forum Play workshops have previously been implemented as an intervention to enhance care providers’ knowledge and foster behavioral change regarding abuse in health care in Sri Lanka and Sweden demonstrating promising outcomes [18,19].

To uphold women’s constitutional rights to safe motherhood and reproductive health, the Government of Nepal enacted the Safe Motherhood and Reproductive Health Rights Act in 2018, which explicitly recognizes RMC as a fundamental right and mandates its provision in both public and private health facilities [20]. However, only 17% of women in Nepal reported that they received RMC [21]. Based on the listed disrespect and abuse in the landscape analysis, there is a high prevalence of disrespect and abuse reported by women [12]. In Nepal, healthcare providers’ conditions to provide RMC are often hampered by high workload, lack of adequate resources and training, and structural as well as cultural barriers. A higher client-to-provider ratio was found to be associated with lower levels of RMC practice in southwestern Nepal [22]. Integrating Forum play into healthcare training in Nepal can serve as a valuable tool to enhance the delivery of RMC by addressing provider stressors, improving communication skills, and promoting empathetic interactions between healthcare providers and women. Health care providers play a major role in achieving RMC, but there is a lack of studies on the perspective of care providers as well as tested interventions to promote RMC in Nepal. The aim of this study was to assess the effectiveness of a pilot Forum Play intervention in promoting respectful maternity care by investigating self-reported perception and behaviour among care providers.

In November 2023, two half-day Forum Play workshops were conducted with the intervention group. Forum Play, a participatory theatre method developed in Sweden by Katrin Byréus [23] and inspired by the work of Brazilian theatre practitioner Augusto Boal [24], engages participants in creating scenes from their own experiences to illustrate situations of oppression. The intervention was grounded in the theoretical frameworks of Freire’s Pedagogy of the Oppressed [25] and Boal’s Theatre of the Oppressed [24], adapted to the healthcare context. In addition, Sexual and Reproductive Health and Rights (SRHR) [26] informed the overall conceptual framework of the study. Together, these perspectives emphasise critical reflection, participation, and empowerment in addressing oppressive practices within care settings. Guided by these principles, Forum Play provided a structured and participatory space for healthcare providers to examine power dynamics, recognise potential violations of SRHR, and rehearse more respectful, rights-based approaches to maternity care.

In each workshop, participants were invited to share their experiences of abuse of women during labour and delivery, enabling everyone to hear and reflect on one another’s stories and to engage with the sensitivity of the theme. From these shared accounts, two cases were selected for enactment through Forum Play. Participants were then randomly divided into two groups, each rehearsing for fifteen minutes before performing their skit. The plays depicted scenarios of disrespect and abuse during pregnancy and childbirth, with roles such as oppressor, oppressed, and bystander. The remaining participants, acting as ‘spect-actors’ (who both observe and actively engage in enacting scenarios) [24], observed closely and were encouraged to interrupt the performance whenever they perceived that abusive behaviour had occurred or was about to occur. They could then intervene by replacing the character, demonstrating abusive behaviour, enacting and testing alternative, respectful responses. These interventions included not only verbal strategies but also non-verbal gestures such as gentle touch or eye contact with the patient. Multiple alternatives were attempted, demonstrating how bystander engagement and different strategies could help counteract disrespect and abuse and promote respectful care.

The workshops were facilitated by an expert Swedish drama pedagogue, with additional support from two artists of Actors’ Studio Nepal (a local drama group) to exchange and strengthen local capacity in Forum Play.

Methodology

Research tool

A structured questionnaire was developed based on an extensive literature review and authors’ experience. The questionnaire was divided into three parts. Details of the tool are presented in Table 1.

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Table 1. Description of research tool.

https://doi.org/10.1371/journal.pone.0349437.t001

The tool was pre-tested among a 10% sample size of the intervention group, and a few necessary modifications were made. The Cronbach’s alpha for part II (views and acting on disrespect and abuse) question was 0.61 in pretest and 0.64 in posttest. Likewise, Cronbach’s alpha for perception towards respectful maternity care was 0.70 in pretest and 0.75 in posttest. A definition of disrespect and abuse was provided to participants as a note to enhance the objectivity of the part II questions (Table 1). The questionnaire was translated into Nepali and then independently back translated into English by subject experts to ensure accuracy and equivalence prior to pretesting. Data were collected using the Nepali version of the questionnaire, administered in a paper-and-pencil format.

Results

A total of 100 participants were recruited for the study in baseline, and all were followed-up after a two-month interval. There was no sample attrition in the follow-up data collection. The process of recruitment and data collection in the study has been displayed in Fig 1.

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Fig 1. Flow diagram outlining the study process.

Participants were divided into intervention and control groups. Forum Play workshops were conducted as intervention.

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Background characteristics of the participants

The mean age of care providers was 31.1 years in the intervention group and 31.4 years in the control group. No statistically significant differences were found between the groups with regards to socio-demographic variables [age (p = 0.87), sex (p = 0.37), ethnicity (p = 0.41), marital status (p = 0.80), education (p = 0.45), occupation (1.00) and work experience (p = 0.09)]. The background characteristics of the groups are illustrated in Table 2.

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Table 2. Background characteristics of the participants (N = 100).

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Perceptions and behaviour on disrespect and abuse of women

Responses regarding perception and behaviour on disrespect and abuse of women during facility-based birth changed significantly in the intervention group after the intervention, while no such changes were observed in the control group. In the intervention group, the proportion of participants who reported hearing about disrespect and abuse in their workplace increased from eight (32%) before to 14 (56%) after the intervention. At baseline, most participants reported not having been exposed to such situations [21 (84%) in the intervention group and 55 (73.3%) in the control group]. After the intervention, however, only nine (36%) of the intervention group reported no exposure.

Regret for not acting against disrespect and abuse was also more common after the intervention: 10 (40%) of the intervention group expressed regret compared to none before the intervention, whereas only 4% of the control group expressed such regret at baseline. Importantly, no participant in either group reported personally engaging in disrespect or abuse even after the intervention.

At baseline, there was no statistically significant difference in perception and behaviour on disrespect and abuse of women between the groups (p = 0.09–0.35). By follow-up, however, significant differences were observed (p < 0.001–0.004) with moderate to large effect sizes (0.33–0.61) (Tables 3 and 4).

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Table 3. Baseline perception and behaviour on disrespect and abuse of women (N = 100).

https://doi.org/10.1371/journal.pone.0349437.t003

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Table 4. Follow-up perceptions and behaviour on disrespect and abuse of women (N = 100).

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Perception towards respectful maternity care

Although participants in both groups generally reported positive perceptions of RMC, negative perceptions persisted in key areas (mean score <4), particularly regarding labor companionship and the women’s preferred birth positions (Table 5). At follow-up, median perception scores increased in the intervention group but decreased in the control group (Table 6).

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Table 5. Item wise mean perception score towards respectful maternity care.

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Table 6. Difference between the groups regarding perception towards respectful maternity care before and after the intervention.

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A Mann–Whitney U test showed no significant difference between groups at baseline (z = −0.120, p = 0.90, r = 0.01), but a significant difference at follow-up (z = −3.25, p = 0.001, r = 0.32). Similarly, the Wilcoxon signed-rank test (Table 7) revealed a significant improvement in the intervention group from baseline to follow-up (z = −3.073, p = 0.002, r = 0.61), while no significant change was observed in the control group (z = −0.120, p = 0.90, r = 0.05).

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Table 7. Comparison of perception score towards respectful maternity care before and after the intervention using Wilcoxon signed-rank test.

https://doi.org/10.1371/journal.pone.0349437.t007

Discussion

Disrespect and abuse during facility-based birth is a form of abuse in health care [31–33]. This study evaluated the effectiveness of Forum Play in training care providers to recognize and respond to such behaviors and to promote respectful maternity care. Findings showed significant changes in the intervention group, with more participants reporting awareness of disrespect and abuse in their workplace after the intervention (56% vs. 32% before). Additionally, 40% expressed regret for not acting against such situations after the intervention, compared to none before. These shifts were not observed in the control group. Similar results have been reported in Sweden, where Forum Play workshops improved staff members’ ability to act in situations of abuse in health care [19]. Strengthening providers’ capacity to recognize and address disrespect and abuse is critical, as this directly contributes to women’s likelihood of receiving RMC [34].

A study in Sri Lanka using Forum Play with maternity staff found that participants later reported more frequent involvement in situations of disrespect and abuse of women [18]. In contrast, no participants in our study admitted personal involvement after the intervention, even though some had shared such experiences during the workshops. This difference may reflect contextual factors in Nepal, where admitting involvement in disrespectful care carries stigma or fear of professional repercussions, most likely leading to underreporting. While Forum Play provides a safe space for reflection, translating this into honest acknowledgment remains challenging. Interventions should therefore address both awareness and the cultural or structural barriers that hinder open reporting of mistreatment.

The findings of this study can be interpreted in relation to the theoretical frameworks underpinning the intervention. SRHR provided the overarching lens, emphasising dignity, autonomy, and the right to respectful maternity care [26]. Freire’s Pedagogy of the Oppressed contributed the concept of critical consciousness; whereby healthcare providers are encouraged to reflect on and question normalized practices that perpetuate disrespect and abuse [25]. Similarly, Boal’s Theatre of the Oppressed informed the use of experiential and participatory learning through role-play, enabling participants to rehearse alternative actions and challenge power hierarchies in a safe environment [24]. Together, these frameworks helped explain the observed improvements in awareness, perceptions, and willingness to act, as they fostered reflection, dialogue, and embodied learning beyond traditional didactic training approaches.

Overall, participants in both groups reported positive perceptions of RMC, consistent with findings from Nigeria where providers generally held favorable views [35]. In our study, providers strongly endorsed principles such as obtaining informed consent, ensuring women’s safety during care, and providing equal treatment regardless of background. Importantly, the intervention group showed an increase in mean perception scores at follow-up, echoing results from Kenya where similar training enhanced providers’ recognition of women’s rights, including informed consent privacy, and dignity [36]. These findings suggest that while baseline perceptions of respectful care may be positive, participatory interventions can strengthen providers’ awareness and commitment towards RMC.

In our study, negative perceptions persisted in certain areas, such as allowing birth companions and supporting the women’s preferred birth positions, despite the intervention. In contrast, midwives in Zimbabwe demonstrated improved women-centered practices following RMC training [37]. This suggests that combining Forum Play with targeted training on specific components of RMC may be necessary to strengthen providers’ positive perceptions and support for these practices in the Nepalese context. Moreover, structural constraints such as workload, resource limitations, and working conditions significantly influence providers’ ability to implement RMC. Therefore, interventions should not focus solely on individual behaviour change but should also address systemic barriers to achieve sustainable improvements in RMC.

At baseline, there were no statistically significant differences regarding views on disrespect and abuse of women between intervention and control groups whereas significant differences were observed at follow-up. This indicates that Forum Play has the potential to engage and train the care providers to not only increase awareness but also act against disrespect and abuse of women during facility-based birth. Interventions that encourage active participation, role-play, and reflection as Forum Play are found to be particularly effective in shifting mindsets compared to didactic approaches. Furthermore, raising awareness at the provider level creates a foundation for broader systemic change, as sensitized providers are more likely to advocate for respectful practices within their institutions. The findings are consistent with the study done in Sri Lanka, which reported that the intervention enhanced the abilities of health care providers to recognize disrespect and abuse of women, an essential first step in reducing such practices [18]. In contrast, the study among maternity care providers in Sweden could not confirm an increased awareness of abuse in health care [19], possibly due to differences in setting, cultural context, or baseline levels of awareness.

In our study, no significant difference was observed in the median perception score towards RMC between intervention and control groups at baseline; however, a significant difference emerged at follow-up. The intervention group showed a higher median perception score with a large effect size (z = −3.073, p = 0.002, r = 0.61). This finding aligns with a quasi-experimental study among nursing students in Nepal, where online education significantly improved positive perceptions of RMC [38]. Similarly, a mixed-methods systematic review reported that educational interventions enhanced knowledge and perceptions of respectful care while reducing women’s experience of mistreatment [39]. These findings suggest that targeted interventions are effective in shaping providers’ attitudes and awareness regarding RMC. Improved perceptions among healthcare providers are important because they represent a critical first step towards fostering behavioral change in clinical practice.

Conclusion

Self-reported perceptions and behaviors of care providers improved in the intervention group after the training. Forum Play, by rehearsing real-life situations, proved to be a promising approach for raising awareness and fostering behavior change. Our findings indicate that it can effectively promote respectful maternity care in Nepal by preparing care providers to prevent disrespect and abuse during labor and delivery. However, the sample size was very small, and the study did not rely on direct observation of actual behavior change. To more rigorously establish the effectiveness of the Forum Play intervention, it should be implemented on a larger scale across maternity care settings, with exploration of women’s experience.

Supporting information

Acknowledgments

We are indebted to Ms. Agneta Josephson, an expert drama pedagogue for coming all the way from Sweden to help and support us by leading the Forum Play workshops enthusiastically. We are thankful to Mr. Anup Baral, director and Mr. Dev Neupane, theatrical producer of Actors’ Studio Nepal for their guidance and support in conducting the workshops. Our special thanks go to Dr. Anmol Prasad Shrestha, Project Officer, National Institute for Health and Care Research for Multiple Long-term Conditions, Kathmandu, Nepal and Dr. Megha Kasaju, Community Physician for making the workshops successful through their expertise as language facilitators between the drama pedagogue and workshop participants. We would like to extend our sincere thanks to all the participants in the study.