Despite South Africa’s significant investment in maternal health care and near-universal access to facility-based births, many women continue to endure disrespect, neglect and abuse while giving birth, experiences that experts warn are driving mothers away from seeking timely medical care and contributing to preventable deaths and complications.
Now, a groundbreaking new study published in The Lancet Regional Health – Africa has found that improving teamwork, communication and organisational culture inside maternity wards can dramatically improve women’s childbirth experiences, even in under-resourced public health facilities.
The study, led by the South African Medical Research Council (SAMRC) and the University of KwaZulu-Natal, evaluated the Strengthening Teamwork and Respect (STAR) intervention across nine districts in KwaZulu-Natal.
Researchers found that when maternity healthcare workers were encouraged to reflect on how women experience care and empowered to introduce practical changes within existing resources, patients reported better communication, greater respect, increased autonomy and more supportive treatment during childbirth.
The findings come amid growing concern over the treatment of women in labour wards across South Africa. A 2020 study published by the National Library of Medicine found that disrespect and abuse during childbirth were common in midwife-led obstetric units in Tshwane, raising alarm about the state of maternal care in public facilities.
The latest study found that the greatest improvements were experienced by women from poorer households and those who had attended fewer antenatal visits, groups considered especially vulnerable to poor maternal outcomes.
The STAR intervention brought together maternity teams in facilitated learning sessions where nurses, midwives and doctors reflected on workplace culture, teamwork and patient interactions. These sessions allowed staff to identify challenges and implement solutions tailored to their own facilities.
Surveys conducted with postpartum women and maternity staff before and after the intervention showed measurable improvements not only in women’s experiences of care, but also in organisational learning culture within maternity units.
Researchers said the intervention strengthened teamwork, encouraged reflection and improved systems for continuous learning and accountability.
Dr Neil Moran, head of obstetrics and gynaecology for the KwaZulu-Natal department of health, said respectful maternity care remains a priority for the province.
“For this to happen, health workers of different categories and seniority must also support each other and treat each other with respect, so that they work well as a team with a common goal to provide a positive experience for their patients,” Moran said.
He described the STAR project as an innovative approach to improving maternal health care by encouraging front-line health workers to reflect on how patients perceive their care and what immediate improvements could be made using available resources.
“The project put the initiative in the hands of the health worker teams on the ground, while at the same time involving and getting buy-in from facility, district and provincial management to provide positive reinforcement and enable successful implementation,” he said.
Moran added that the study’s findings provide evidence that managerial support and stronger teamwork can positively influence women’s experiences during childbirth and improve morale among healthcare workers.
“This in turn makes a positive impact on the organisational culture in the maternity unit, making the work experience more fulfilling for the health worker,” he said.
No midwife, nurse or doctor goes to work intending to cause harm to women in labour. However, the systems they work in can make it difficult to provide respectful, supportive care
— Prof Tanya Doherty
Prof Tanya Doherty, the project lead and chief specialist scientist at the SAMRC, said the study offers important new insights into how health worker-led interventions can improve respectful maternity care.
“This is the first study to assess an intervention that addresses both organisational learning culture and women’s experience of care,” she said.
“No midwife, nurse or doctor goes to work intending to cause harm to women in labour. However, the systems they work in can make it difficult to provide respectful, supportive care.”
Dr Christiane Horwood, co-investigator on the study, said the findings highlighted the importance of strengthening the systems in which healthcare workers operate.
“Our findings highlight how creating space for collective reflection, learning, and locally led action can strengthen both teamwork and accountability, ultimately improving women’s experiences of care,” she said.
