WHO recommendation on respectful maternity care during labour and childbirth

WHO recommendation on respectful maternity care during labour and childbirth



Respectful maternity care – which refers to 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 – is recommended.



Publication history

First published: February 2018

Updated: No update planned

Assessed as up-to-date: February 2018



  • Provision of respectful maternity care (RMC) is in accordance with a human rights-based approach to reducing maternal morbidity and mortality. RMC could improve women’s experience of labour and childbirth and address health inequalities. 
  • There is limited evidence on the effectiveness of interventions to promote RMC or to reduce mistreatment of women during labour and childbirth. Given the complex drivers of mistreatment during facility-based childbirth, reducing mistreatment and improving women’s experience of care requires interventions at the interpersonal level between a woman and her health care providers, as well as at the level of the health care facility and the health system.
  • Effective communication and engagement among health care providers, health service managers, women and representatives of women’s groups and women’s rights movements is essential to ensure that care is responsive to women’s needs and preferences in all contexts and settings. 
  • Interventions should aim to ensure a respectful and dignified working environment for those providing care, acknowledging that staff may also experience disrespect and abuse in the workplace and/or violence at home or in the community.



Globally, approximately 140 million births occur every year (1). The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour (2, 3). However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis (4, 5). Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth (6). The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies (7).

Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services (8). In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth.

As highlighted in the World Health Organization (WHO) framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes (9).

This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings. In addition to establishing essential clinical and non-clinical practices that support a positive childbirth experience, the guideline highlights unnecessary, non-evidence-based and potentially harmful intrapartum care practices that weaken women’s innate childbirth capabilities, waste resources and reduce equity.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.



These recommendations were developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development (10). Briefly, these procedures include: (i) identification of priority questions and outcomes; (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (11) and Confidence in the Evidence from Reviews of Qualitative research (CERQual) (12) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions.

The GRADE evidence-to-decision (EtD) framework (13), an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at two technical consultations in May and September 2017. In addition, relevant recommendations from existing WHO guidelines approved by the Guidelines Review Committee (GRC) were systematically identified and integrated into this guideline for the purpose of providing a comprehensive document for end-users.


Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • For women in labour (P), does a policy that promotes respectful, dignified, women-centred maternity practice (I), compared with usual practice (C), improve birth outcomes (O)?


Evidence summary

Evidence on the effects of RMC interventions on birth outcomes was derived from a systematic review of five studies that were conducted in Africa (Kenya, South Africa [2 studies], Sudan and the United Republic of Tanzania) (14).

The review found no studies from high-income countries (HICs). Two of the included studies were cluster randomized controlled trials (1 cRCT with only 2 sites and the other with 10 sites) and three were before–after studies. Control (or preintervention) sample sizes ranged from 120 to 2000 participants across studies and post-intervention samples ranged from 105 to 1680 participants. Most of the interventions included multiple components, with an emphasis on community engagement as well as on changes on the part of the staff to increase RMC and reduce disrespect and abuse. Types of components included in the RMC interventions were: training in values and attitudes transformation; training in interpersonal communication skills; setting up quality improvement teams; monitoring of disrespect and abuse; staff mentorship; improving privacy in wards (e.g. with curtains or partitions between beds); improving staff conditions (e.g. providing tea for those on shift); maternity open days; community workshops; mediation/alternative dispute resolution; counselling of community members who have experienced disrespect and abuse; providing a method for submitting complaints; and educating women on their rights. One intervention was focused on companionship in labour, with an emphasis on RMC, and one was focused on a communication-building package with staff. The nature of “usual practice” was not reported in any of these studies.

 All the studies reported on aspects of disrespectful or respectful care based on women’s self-report. In two studies, self-reported data were accompanied by researchers’ observational data. One study presented data on episiotomy, but none of the other studies provided data on the clinical outcomes pre-specified to guide decision-making for this recommendation. Data were not pooled due to heterogeneity across studies in study design and the definitions and reporting of outcomes. Data were relatively sparse and all of the studies were at unclear or high risk of bias. Therefore, the level of certainty of the evidence was downgraded for risk of bias for all outcomes.


RMC intervention compared with usual practice (no RMC intervention)


Maternal outcomes

Birth experience

Respectful care: Three studies (1 cRCT and 2 before–after studies) reported on the experience of respectful care. Moderate-certainty evidence suggests that women are probably more likely to report experiencing respectful care with RMC interventions than without RMC interventions (1 cRCT, approximately 3000 participants, adjusted odds ratio [aOR] 3.44, 95% CI 2.45–4.84). This finding is supported by the observational studies: one before–after study reported that 22.8% versus 0% of participants rated respect as “excellent” at postpartum follow-up, and the other reported that respectful care was experienced by 94.7% versus 89.7%, in the post- and pre-intervention groups, respectively.

Maternal satisfaction: Low-certainty evidence derived from one cRCT suggests that there may be little or no difference between having an RMC intervention and not having one in terms of the proportion of women reporting being very satisfied with care (aOR 0.98, 95% CI 0.91–1.06).

Quality of care: Moderate-certainty evidence from one cRCT suggests that RMC probably leads to more frequent experiences of good-quality care overall (approximately 3000 participants, aOR 6.19, 95% CI 4.29–8.94). Observational data are consistent with this evidence.

Experience of mistreatment

Experience of disrespectful or abusive care: One cRCT and two before–after studies reported this outcome. Moderate-certainty evidence suggests that RMC probably reduces experiences of disrespectful or abusive care by about two thirds (1 cRCT, approximately 3000 participants, aOR 0.34, 95% CI 0.21–0.57). Observational data are consistent with the cRCT, with an estimated 40% reduction in disrespectful or abusive care after the RMC intervention in one study, and a 52% reduction in another.

Lack of privacy: One cRCT and two before–after studies reported this outcome; the evidence was of very low certainty, however, as a range of different measures and inconsistent findings were reported.

Physical abuse: Moderate-certainty evidence from four studies (2 cRCTs and 2 before–after studies) suggests that RMC interventions probably reduce physical abuse. One cRCT reported a reduction in physical abuse in the intervention arm from a baseline average of 2% to 1% at follow-up and an increase in the control arm from a baseline average of 3% to 4% at follow-up. The other cRCT (approximately 3000 participants) reported an aOR of 0.22 (95% CI 0.05–0.97). One before–after study found that observed physical abuse reduced from 3.5% before the RMC intervention (677 participants) to 0.4% afterwards (523 participants), and the other reported a reduction in observed fundal pressure from 3.4% (208 participants) before to 0.2% (459 participants) after, as well as a reduction in “episiotomy without anaesthesia” from 4.3% before to 0% after.

Verbal abuse: Low-certainty evidence based on three studies (1 cRCT, and 2 before–after studies) suggests that there may be little or no difference in verbal abuse, as the estimates of effect in two studies (1 cRCT and 1 before–after study) included the possibility of increase in verbal abuse, while the third study showed an absolute reduction in verbal abuse of 49%.

Neglect/abandonment: Low-certainty evidence based on four studies (2 cRCTs, and 2 before–after studies) suggest that RMC interventions may reduce neglect and abandonment. One cRCT found a 64% reduction (approximately 3000 participants; aOR 0.36, 95% CI 0.19–0.71) and the other cRCT reported an increase from 12% to 16%. The observational studies found no clear difference.

Non-dignified care: Low-certainty evidence from one cRCT suggests that RMC may reduce non-dignified care (approximately 3000 women, aOR 0.58, 95% CI 0.30–1.12). This evidence is supported by a before–after study during which researchers found large reductions in various aspects of non-dignified care (e.g. the provider not introducing herself to the woman, failure to provide a clean bed for the woman, and the woman not being cleaned after birth).

Non-consented care and detention: Evidence on these outcomes is of very low certainty, partly because it was derived from before–after studies with design limitations.

Perineal/vaginal trauma

Episiotomy: The findings of one small study suggested that RMC interventions may reduce episiotomy (low-certainty evidence). The episiotomy rate was reduced by an average of 13% (from 34% to 21%) in the RMC arm of this study compared with an average of just 1% (from 40% to 39%) in the control arm.

Mode of birth, duration of labour, use of pain relief

The review found no evidence on these outcomes.


Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: The review found no evidence on this outcome.


Additional considerations

The systematic review evidence on RMC is derived from studies conducted only in Africa and might not be generalizable to other regions.



A qualitative review (15) on RMC included 67 qualitative studies conducted in 32 countries, including countries in sub-Saharan Africa (6 countries), Asia (7), Oceania (1), Europe (8), the Middle East and North Africa (5), North America (2) and Latin America (3). The studies reported on the experiences of women, family members, and multiple cadres of health care providers and administrators. The review concluded that women placed high value on RMC, and this finding was consistent across countries and settings (high confidence in the evidence).

The findings indicate that women consistently appreciate and value RMC, and providers perceive RMC to be a critical component of providing safe, good-quality care (high confidence in the evidence). Globally, women’s and providers’ perspectives on what constitutes RMC are also quite consistent. These stakeholders identify the key components of RMC as: being free from harm and mistreatment; having privacy and confidentiality; dignified care; receiving information and being supported in the process of informed consent; continuous access to family and community support; high-quality physical environment and resources; equitable maternity care; effective communication; having choices and the opportunity to make decisions; availability of competent and motivated human resources; and receiving efficient, effective and continuous care.

The evidence shows that there is some variability in the relative importance of some aspects of RMC. For example, women living in HICs emphasize their rights to decision-making and active participation in their childbirth experience (moderate confidence in the evidence). Comparatively, women in lower-income countries are less likely to demand personal choices and decision-making over their childbirth process (moderate confidence in the evidence).



No research evidence was found on the costs or cost-effectiveness of RMC.

Additional considerations

Developing a policy that promotes RMC needs to address multiple RMC domains, in terms of interactions between individual women and health care providers, as well as interactions at the health system level. System-level quality improvement is likely to require resources to sustain staff behaviour change. This may include restructuring clinical training curricula for midwives, nurses and physicians, increasing the numbers of health care providers on staff, improving remuneration and respect for staff, and upgrading the physical environment. The design of the labour ward may present a key barrier to some components of RMC (e.g. labour companionship) in many settings. However, several aspects of RMC, particularly those at the interpersonal level (e.g. improving communication, respecting women’s choices during labour and childbirth, reducing physical and verbal abuse, improving privacy and maintaining confidentiality), would require comparatively few resources to address them.


No direct evidence on the impact of RMC on equity was found. However, indirect evidence from a qualitative review on facilitators and barriers to facility-based birth (8) indicates that mistreatment and abuse by health workers is a substantial barrier to the use of facility-based birth services in low- and middle-income countries (LMICs) (high confidence in the evidence). This suggests that mistreatment contributes to health inequalities related to the use of facility-based birth services. Further indirect evidence from the RMC qualitative review (15) indicates that respecting the culture, values and beliefs of individual women and local communities is important to women (high confidence in the evidence). The evidence also indicates that providing the same standard of maternity care for all, regardless of age, ethnicity, race, sexuality, religion, socioeconomic status, HIV status, language or other characteristics is important to women (moderate confidence in the evidence). Inequity can result from receiving judgemental care from health care providers, and ensuring non-judgemental care for women may be important to improve equity (low confidence in the evidence).

Additional considerations

A policy of RMC is in accordance with the general principles of the Human Rights Council’s 2012 Technical guidance on the application of a human-rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality (16).



Findings from a qualitative review (15) indicate that women appreciate RMC across countries and settings (high confidence in the evidence). Stakeholders (including women, providers and administrators) emphasized the theoretical importance of providing and ensuring RMC for all women. Review findings also suggest that efforts to address or improve RMC may be acceptable to health care providers (high confidence in the evidence). However, in environments where resources are limited, health care providers believe that RMC could increase their workload and could reduce their ability to provide quality care to all women. For example, they perceive that RMC could require spending more time with individual women, which may compromise care for other women who are left unattended. Thus, acceptability among health care providers may vary, depending on the available time and the specific RMC intervention. The review found little evidence on acceptability of specific RMC interventions that have been implemented.

Additional considerations

Mistreatment of women during childbirth is often due to existing social norms and in some settings it may be regarded by health care providers and other stakeholders as acceptable (17–19).



Evidence from a qualitative review (15) suggests that most health care providers would like to provide respectful, dignified and woman-centred care but may feel unable to do so due to resource constraints (high confidence in the evidence). Addressing some aspects of RMC, such as improving the physical environment and ensuring adequate numbers of trained staff, is likely to be resource-intensive, and therefore feasibility and sustainability of these aspects may be limited in poorly resourced settings. Thus, the introduction of RMC policies is most likely to be feasible in settings where resources are adequate. Nevertheless, the fact that all five studies demonstrating impact of RMC policies (14) were conducted in low-resource settings implies that they are feasible where increasing RMC in the health system is prioritized on the health care agenda. Additional considerations While RMC may be viewed positively by stakeholders in a general sense, changing cultural norms and established behaviours in health care facilities is often challenging, particularly in settings where mistreatment of women during childbirth is considered to be socially acceptable (17–19).


Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:




Implementation considerations

The successful introduction of evidence-based policies related to intrapartum care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.

The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.

An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.

Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

Health policy considerations 

  • A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.
  • To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages. 
  • To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.
  • To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

Organizational or health-system-level considerations 

  • Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.
  • Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible. 
  • Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools.
  • The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labour). 
  • Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For health care facilities without availability of caesarean section, context- or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop. 
  • Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient. 
  • Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies. 
  • Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities. 
  • Behaviour change strategies aimed at health care providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched. 
  • Successful implementation strategies should be documented and shared as examples of best practice for other implementers. User-level considerations 

Community-level sensitization activities should be undertaken to disseminate information about: 

  • respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities; 
  • facility-based practices that lead to improvements in women’s childbirth experience (e.g. RMC, labour and birth companionship, effective communication, choice of birth position, choice of pain relief method);
  • and unnecessary birth practices that are not recommended for healthy pregnant women and that are no longer practised in facilities (e.g. liberal use of episiotomy, fundal pressure, routine amniotomy).


Research implications

The GDG identified these priority questions related to this recommendation:

  • What are the effects of a policy of RMC on substantive maternal and perinatal outcomes, and on longer-term health and well-being? 
  • Which components/sets of components are the most effective and in which contexts?  
  • What are the best RMC indicators, in terms of validity and responsiveness in clinical settings? 
  • What are the effective strategies for implementing RMC in different LMIC and HIC settings? 
  • What are the innovative approaches that need to be further developed and tested to integrate RMC into quality improvement initiatives?



Related links

WHO recommendations on intrapartum care for a positive childbirth experience

(2018) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health




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Citation: WHO Reproductive Health Library. WHO recommendation on respectful maternity care. (February 2018). The WHO Reproductive Health Library; Geneva: World Health Organization.