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Indicator 10: Person-centered maternity care

This indicator measures the proportion of facilities that provide optimal person-centered maternity care.

Numerator:No. facilities with an average PCMC score of 90 or higher

Denominator:Total no. facilities assessed

× 100

Purpose

Respectful maternity and newborn care—care that is respectful and responsive to the needs, values, and preferences of individuals and their families receiving maternity services12—has become a priority in the global discourse on quality of care due to the widespread mistreatment of women during childbirth globally.3456 Disrespect and abuse and other forms of mistreatment lead to lack of, delayed, inadequate, unnecessary, or harmful care, which undermines health gains for mothers and babies.7 Mistreatment deters women from giving birth in health facilities.89 Respectful care has direct effects on health outcomes through timeliness, effective communication, patient engagement, safety, trust, improved psychosocial health, and patient and provider satisfaction.1011 Further, respectful maternity care, including domains of the person-centered maternity care (PCMC) scale described below, is associated with improved maternal outcomes, such as shorter duration of labor, decreased caesarean and instrumental vaginal birth, lower risk of screening positive for post-partum depression; newborn outcomes including higher five-minute Apgar scores; and post-natal care utilization.121314151617 Disrespect and abuse has also been linked with provider stress and burnout.18

The PCMC scale is a comprehensive measure of women’s experiences during childbirth that measures both responsive and respectful maternity care, with domains for communication and autonomy, dignity and respect, and supportive care (including birth companionship).19 The PCMC scale was initially developed and validated in Kenya and India.2021 Since then it has had widespread uptake with published studies from several countries in Africa, Asia, and the Americas.2223242526272829 In 2022 it was recommended for inclusion in the Service Provision Assessments.

The original PCMC scale includes 30 items (with an additional item on bribes in the India version). A shorter validated version with 13 items, which is strongly correlated with the full version, has also been developed.30 Although the PCMC indicator is not specifically for EmONC, a secondary analysis of data examining the full score, sub-scale scores, and responses to individual items did not find consistent evidence of which items should be prioritized for complications.31

This scale will facilitate a standardized measurement of respectful maternity care across diverse settings to: 1) better understand women’s experiences of care, and 2) inform and evaluate efforts to improve quality and promote implementation and uptake of comprehensive respectful care. Assessing PCMC as a core dimension of the EmONC system will ensure that experience of care is visible in efforts to improve EmONC, so that women with complications receive responsive and respectful care, as well as the technical care needed to manage their complications. It will also ensure that planning to improve EmONC keeps the woman at the center of care.

Data collection and calculation

The numerator for this indicator is the number of facilities with an average PCMC score of 90 or higher. The process for determining facilities’ average PCMC scores can be found in Person-centered maternity care scale, process and instructions for use. The denominator is the number of facilities being assessed.

This indicator is expressed as a percentage.

For routine monitoring, the PCMC survey can be administered periodically over the year as feasible for a facility. For periodic assessments, the PCMC survey can be administered annually over a period of one to three months (instructions for use can be found in Person-centered maternity care scale, process and instructions for use).

Analysis and interpretation

The benchmark for this indicator is for 100% of facilities to have an average PCMC score of 90 or above, with 0 women reporting abuse. If a country or sub-national area does not meet this benchmark, it means that women are having sub-optimal experience of care during childbirth and further investigation is required. Disaggregation by geographical area, level of facility, EmONC classification, and/or managing authority may uncover systemic problems.

It may be useful to interpret this indicator together with other indicators such as health workforce adequate for caseload, health workforce wellbeing, or equipment, drugs and supplies, in order to get an indication of whether providers are working under particularly stressful conditions, which have been associated with low levels of respectful care.32

The PCMC indicator can be used for various purposes including to inform quality improvement activities, for evaluation to assess the impact of interventions, for monitoring to assess changes over time, and for research to assess determinants and consequences of PCMC. Like any composite indicator, the PCMC score by itself will not tell you the specific point at which the problem is occurring or why. Examining the sub-scale scores and responses to individual items will however provide guidance on where the main gaps are and help inform quality improvement. For example, prior work in Ghana, Kenya, and India identified communication and autonomy as major areas of concern, with individual items highlighting that providers often to do not explain what they are doing to women and do not obtain consent.33 Such information for a facility provides actionable data to improve women’s experience.

Supplemental studies

To identify specific groups experiencing worse PCMC, facilities can collect additional data alongside the PCMC scale items to help disaggregate average PCMC scores.

Sample sizes may need to be increased to facilitate disaggregation for some of these variables.

Useful links

  1. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US); 2001 (accessed 2020 December 30). ↩︎

  2. Afulani PA, Diamond-Smith N, Golub G, Sudhinaraset M. Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reprod Health. 2017;14. doi:10.1186/s12978-017-0381-7 ↩︎

  3. Bowser D, Hill K. Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth: Report of a Landscape Analysis | Traction Project. Published 2010. Accessed August 31, 2015. ↩︎

  4. Abuya T, Warren CE, Miller N, et al. Exploring the Prevalence of Disrespect and Abuse during Childbirth in Kenya. PLoS One. 2015;10(4). doi:10.1371/journal.pone.0123606 ↩︎

  5. Bohren MA, Vogel JP, Hunter EC, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12(6). doi:10.1371/journal.pmed.1001847 ↩︎

  6. Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77. doi:10.1186/s12978-019-0729-2 ↩︎

  7. Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. Published online September 2016. doi:10.1016/S0140-6736(16)31472-6 ↩︎

  8. Moyer CA, Mustafa A. Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reprod Health. 2013;10:40. doi:10.1186/1742-4755-10-40 ↩︎

  9. Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP, Gülmezoglu AM. Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reprod Health. 2014;11(1):71. doi:10.1186/1742-4755-11-71 ↩︎

  10. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1). doi:10.1136/bmjopen-2012-001570 ↩︎

  11. Oliveira VC, Refshauge KM, Ferreira ML, et al. Communication that values patient autonomy is associated with satisfaction with care: a systematic review. J Physiother. 2012;58(4):215-229. doi:10.1016/S1836-9553(12)70123-6 ↩︎

  12. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. In: The Cochrane Collaboration, Hodnett ED, eds. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2013 (accessed 2013 August 6). ↩︎

  13. Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2017. doi:10.1002/14651858.CD003766.pub6 ↩︎

  14. Sudhinaraset M, Landrian A, Afulani PA, Diamond-Smith N, Golub G. Association between person-centered maternity care and newborn complications in Kenya. Int J Gynaecol Obstet. Published online September 23, 2019. doi:10.1002/ijgo.12978 ↩︎

  15. Sudhinaraset DrM, Landrian MsA, Golub MsGM, Cotter MsSY, Afulani DrPA. Person-centered maternity care and postnatal health: Associations with maternal and newborn health outcomes. AJOG Global Reports. Published online January 27, 2021:100005. doi:10.1016/j.xagr.2021.100005 ↩︎

  16. Minckas N, Gram L, Smith C, Mannell J. Disrespect and abuse as a predictor of postnatal care utilisation and maternal-newborn well-being: a mixed-methods systematic review. BMJ Glob Health. 2021;6(4):e004698. doi:10.1136/bmjgh-2020-004698 ↩︎

  17. Attanasio LB, Ranchoff BL, Paterno MT, Kjerulff KH. Person-Centered Maternity Care and Health Outcomes at 1 and 6 Months Postpartum. Journal of Women’s Health. Published online September 2, 2022. doi:10.1089/jwh.2021.0643 ↩︎

  18. Afulani PA, Kelly AM, Buback L, Asunka J, Kirumbi L, Lyndon A. Providers' perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya. Health Policy Plan. 2020 Jun 1;35(5):577-586. doi: 10.1093/heapol/czaa009. PMID: 32154878; PMCID: PMC7225569. ↩︎

  19. Afulani PA, Diamond-Smith N, Golub G, Sudhinaraset M. Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reprod Health. 2017;14. doi:10.1186/s12978-017-0381-7 ↩︎

  20. Afulani PA, Diamond-Smith N, Golub G, Sudhinaraset M. Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reprod Health. 2017;14. doi:10.1186/s12978-017-0381-7 ↩︎

  21. Afulani PA, Diamond-Smith N, Phillips B, Singhal S, Sudhinaraset M. Validation of the person-centered maternity care scale in India. Reprod Health. 2018;15(1):147. doi:10.1186/s12978-018-0591-7 ↩︎

  22. Afulani PA, Phillips B, Aborigo RA, Moyer CA. Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India. The Lancet Global Health. 2019;7(1):e96-e109. doi:10.1016/S2214-109X(18)30403-0 ↩︎

  23. Habib HH, Torpey K, Maya ET, Ankomah A. Promoting respectful maternity care for adolescents in Ghana: a quasi-experimental study protocol. Reproductive Health. 2020;17(1):129. doi:10.1186/s12978-020-00977-w ↩︎

  24. Dagnaw FT, Tiruneh SA, Azanaw MM, Desale AT, Engdaw MT. Determinants of person-centered maternity care at the selected health facilities of Dessie town, Northeastern, Ethiopia: community-based cross-sectional study. BMC Pregnancy Childbirth. 2020;20(1):524. doi:10.1186/s12884-020-03221-2 ↩︎

  25. Rishard M, Fahmy FF, Senanayake H, et al. Correlation among experience of person-centered maternity care, provision of care and women’s satisfaction: Cross sectional study in Colombo, Sri Lanka. PLOS ONE. 2021;16(4):e0249265. doi:10.1371/journal.pone.0249265 ↩︎

  26. Özşahin Z, Altiparmak S, Aksoy Derya Y, Kayhan Tetik B, Inceoğlu F. Turkish validity and reliability study for the person-centered maternity care scale. J Obstet Gynaecol Res. 2021;47(9):3211-3222. doi:10.1111/jog.14913 ↩︎

  27. Ogbuabor DC, Nwankwor C. Perception of Person-Centred Maternity Care and Its Associated Factors Among Post-Partum Women: Evidence From a Cross-Sectional Study in Enugu State, Nigeria. Int J Public Health. 2021;66:612894. doi:10.3389/ijph.2021.612894 ↩︎

  28. Afulani PA, Altman MR, Castillo E, et al. Adaptation of the Person-Centered Maternity Care Scale in the United States: Prioritizing the Experiences of Black Women and Birthing People. Women’s Health Issues. Published online March 9, 2022. doi:10.1016/j.whi.2022.01.006 ↩︎

  29. Stierman EK, Zimmerman LA, Shiferaw S, Seme A, Ahmed S, Creanga AA. Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia. AJOG Global Reports. 2023;3(1):100140. doi:10.1016/j.xagr.2022.100140 ↩︎

  30. Afulani PA, Feeser K, Sudhinaraset M, Aborigo R, Montagu D, Chakraborty N. Toward the development of a short multi-country person-centered maternity care scale. International Journal of Gynecology & Obstetrics. 2019;0(0). doi:10.1002/ijgo.12827 ↩︎

  31. Kapula N, Sacks E, Wang DT, et al. Associations between self-reported obstetric complications and experience of care: a secondary analysis of survey data from Ghana, Kenya, and India. Reproductive Health. 2023;20(1):7. doi:10.1186/s12978-022-01546-z ↩︎

  32. Afulani PA, Kelly AM, Buback L, Asunka J, Kirumbi L, Lyndon A. Providers' perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya. Health Policy Plan. 2020 Jun 1;35(5):577-586. doi: 10.1093/heapol/czaa009. PMID: 32154878; PMCID: PMC7225569. ↩︎

  33. Afulani PA, Phillips B, Aborigo RA, Moyer CA. Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India. The Lancet Global Health. 2019;7(1):e96-e109. doi:10.1016/S2214-109X(18)30403-0 ↩︎