Rethinking Respectful Maternity Care in India

Safe childbirth is not only about clinical survival—it is about dignity. It is about a woman being seen, heard, and treated with respect and kindness, both as an individual and as part of a family. Compassion is not an optional add-on; it is the very foundation of quality maternal healthcare.

This World Health Day, observed on April 7, 2025, marked the launch of a year-long global campaign focused on maternal and newborn health. India has made commendable progress in reducing maternal mortality—declining from 130 per lakh live births in 2014 to 93 per lakh live births in 2021 (SRS) -- a testament to decades of policy commitment and improved access to institutional care. Yet, the quality of care in many public health facilities remains inconsistent and, at times, deeply inadequate.

Compassion Is Not Optional

Compassion is central to quality health and maternity care. It ensures that childbirth is not only clinically safe but also emotionally dignified. Respectful care is increasingly recognised as a right, not a privilege. In recent months, numerous opinion articles by respected medical practitioners discuss the criticality of compassionate care to quality of care.

The concept of respectful maternity care encompasses compassionate care, yet the two are different. The Oxford English Dictionary defines respect (in this context) as polite behaviour or care toward someone or something considered important. Whereas compassion is defined as a feeling of deep sympathy and sorrow for another who is stricken by suffering or misfortune, accompanied by a strong desire to alleviate the suffering. While parameters to define respectful maternity care have been drawn up to some extent, compassion, being an emotion, is far harder to measure.

Disrespect and Mistreatment Leads to Mistrust

Pregnancy is a delicate state for a woman and her family. In a hospital set-up, it is expected that Health Care Providers (HCP) will often face socially difficult situations while dealing with a pregnant woman and her family, such as divulging that the baby may be still-born, mother may have complications or adverse effects of a medication etc. Yet, repeated reports of HCP vs patient-family skirmishes in hospitals flood the news.

These conflicts are indicators of mistrust of the patient and their family on HCP and hospital, manifesting as rage or violence or mishandling of a delicate situation by HCP, at a vulnerable time of the patient and their family. While open conflicts are rare enough to make it to the news, regular disrespect of patients and their family is rampant in both public and private facilities, especially those accessed by low-income groups. Such experiences reduce the trust of the public in public health facilities and deter future health-seeking.

Research indicates that maternal mental stress during pregnancy impacts the psychological constitution of the newborn - affects foetal brain development, particularly in areas like the hippocampus and amygdala – areas responsible for stress response, emotional regulation, and cognitive function, leading to structural and functional changes in the infant's brain.

This begs the question -- what is the impact of a psychologically traumatic delivery experience on the mental state of a woman and her newborn? Would the newborn be psychologically affected? To take the argument further, a pregnant woman who has gone through a disrespectful and humiliating experience in hospital during her previous pregnancy is likely to experience significant fear and apprehension during a subsequent pregnancy. How would this maternal stress impact foetal psychology?

Why is Compassion Missing?

Empathy and compassion are not necessarily instinctive or natural to human beings. Social circumstances, culture and upbringing have a role to play. Other factors are inadequate training/understanding of the importance of the role; lack of ownership of role as health care provider; feeling of being disrespected by superiors; watching and learning disrespectful behaviour displayed by seniors; experiencing no consequences of bad behaviour; innate lack of professionalism; lack of pride in the job; heavy patient load, constant demands, long hours of work and criticism and indiscipline from patients and their family.  

The complications and nuances of health provider-patient interaction need to be experienced for some time before a young doctor or nurse can develop her communication style.

India’s Reality Check

Reports from district hospitals and primary health centres indicate that while access has improved, women still face challenges like lack of privacy, being scolded during labour, and having no one to accompany them. Compassion and empathy during maternity care is a gender indicator. While compassion in care is universally important, empathy in maternity care deserves special mention.

The average age at first pregnancy in rural India is 21 years and over the next few years, most women have completed their family. More than 80% deliveries occur in institutions. These young women delivering in public health facilities often belong to poor families, face extreme gender bias, are uneducated and married off at an early age. They have learnt to be submissive and accommodating, having no voice or agency. The feeling of helplessness and vulnerability in an unfamiliar setting does not find a voice, particularly because of deep gender vulnerabilities and bias. Respectful and compassionate maternity care must be included as a critical indicator of gender equity in health. 

Training the Heart and Mind, Not Just Hands

While clinical skills of medical and paramedical staff are regularly refreshed through Continuing Medical Education, trainings etc, soft skills like communication, empathy, and managing patients with dignity are often overlooked.

Training the heart to be compassionate and disciplining the mind to maintain calmness in adverse circumstances is a skill that every HCP and staff working in a healthcare facility must learn and strengthen. Softer feelings, such as sympathy, empathy, gentleness or compassion need to be evoked and delicately maintained throughout the career of an HCP.

Compassionate care is often discussed in the context of patients, but it begins with the well-being of those who provide it. When healthcare providers—especially in maternity settings—are supported, respected, and not chronically overburdened, they are far more likely to extend dignity, patience, and kindness to those they serve.

Empathy, the ability to understand and share the feelings of another, is the foundation upon which compassion is built. A provider who can empathise with a woman in labour—who can imagine her pain, fear, and vulnerability—is more likely to respond with compassionate action. But this capacity for empathy cannot thrive in environments where staff are overstretched, under-recognised, or emotionally exhausted. In such settings, empathy risks being blunted by burnout.

When carers are cared for, they are better equipped to care for others. Compassionate maternity care, then, is not just a question of provider attitudes—it is a structural issue that demands empathy for the providers themselves.

Innovative methods to train the heart and mind in compassionate and empathetic care are the need of the hour. Strategies also need to be devised to maintain these skills over time. However, this cannot be done by mere theoretical training. Innovative psychologically informed, practically practiced strategies are needed.

Positive reinforcement – Teach, train, handhold and provide supportive supervision to the staff. Provide them thoroughly researched FAQs and other tools that can give them directions to handle delicate situations carefully, hold regular seminars on the issue.  

Recognise, reward, promote and incentivise good performers. Provide them growth opportunities to become a mentor, supervisor, and designated as senior.

Set examples as a leader, explain the importance of every role as part of a bigger picture.

And finally, care for the carer -- provide good facilities of drinking water, toilets, resting space, storage of personal items, creche facilities, counselling, respectful medical care.

Compassion isn’t just a personal trait—it’s a shared responsibility. Caring for caregivers enables them to care better, leading to improved patient experiences and health outcomes.  

Infrastructure Matters Too

Simple and easily achievable parameters of respect such as privacy curtains, clean beds, functional toilets, and a quiet room play an essential role in respectful care. Yet, many facilities in Bihar still lack these basics, especially in labour rooms, which affects both dignity and comfort during childbirth. Health facilities recognise that a pregnant woman does not come alone to the hospital, in fact, it is mandatory for one attendant to accompany her.

However, in the Indian context, women often prefer to be accompanied by two attendants – one woman - often a sister or mother-in-law to help her eat, remain clean, escort her to the toilet etc, as well as a man – husband or brother to fetch medications, food and other requirements while living in the hospital. Often, when both husband and wife are in hospital, so are the other young children. Therefore, hospital infrastructure for the maternity wing cannot mean merely patient beds. Each bed should mandatorily be accompanied by a well-organized, clean waiting area, provision for lodging and boarding space for two attendants, a creche for young children and a safe storage for patient possessions.

Listening to Women’s Voices

States that have institutionalised maternal feedback mechanisms—like satisfaction surveys or grievance redressal boxes—have seen early improvements in service delivery. In many facilities in Bihar, such mechanisms remain either underutilized or non-functional, indicating a need to do more.

Compassion and Empathy Helps Providers Too

When providers are supported, valued, and not overburdened, they are more likely to treat patients with respect. Compassionate care should also mean caring for the carers—addressing their mental health and working conditions.

In the landscape of maternal healthcare, compassion is often framed as an individual provider trait. But in practice, compassion is both relational and systemic—it begins with empathy and must be supported by structures that allow providers to care, not just clinically, but humanely.

Empathy—the ability to emotionally connect with another’s experience—is the seed from which compassionate care grows. A provider who can empathise with a woman in labour, who senses her fear, pain, or confusion, is more likely to offer care that is respectful and kind. But empathy requires emotional availability—and this is not possible when providers themselves are unsupported, overstretched, and unseen.

Across India, where institutional deliveries have risen significantly—from 38.7% in 2005-06 to 88.6% in 2019-21 (NFHS-5)—the demand on health personnel has multiplied. Many labour rooms function with minimal staff, high caseloads, and inadequate infrastructure. In such environments, burnout is not a risk but a reality. Studies have shown that providers often experience moral distress when they are unable to deliver the quality of care they aspire to, due to systemic constraints (Singh et al., 2018, BMJ Global Health).

One telling example comes from a district hospital in Bihar where nurse-midwives, responsible for multiple deliveries per shift, reported feeling “helpless” when they could not offer even basic emotional support to women in pain. As one nurse put it, “We want to sit and talk to her, calm her—but who will do the others [deliveries]?”

At the same time, interventions that support providers have shown transformative potential. In facilities where government and non-government initiatives trained nurses and obstetricians not only in clinical protocols but also in interpersonal communication and stress management, there was a measurable improvement in client satisfaction and a decline in instances of reported mistreatment (UNFPA Bihar Field Reports, 2022–24).

Moreover, a 2023 study on Respectful Maternity Care pilot implementation in Bihar (Roy et al., supported by ASCI and UNFPA) found that when providers felt heard by supervisors and supported through team-based approaches, their own empathy levels increased—and so did their commitment to ensuring every woman had a positive birthing experience.

These examples illustrate a critical point: compassion is not just a “soft skill” demanded of frontline workers—it is a two-way process that must be cultivated and institutionalised. When carers are cared for—through adequate staffing, emotional support, and recognition of their work—they become more capable of empathetic engagement. Empathy fuels compassion, and compassion, in turn, improves both patient satisfaction and clinical outcomes.

Promoting Empathy, Discipline Among Patients & Families
While we promote compassionate care among health providers, it is also important for patients and families to know and follow hospital rules. How to behave in a hospital -- dos and don’ts. During ante-natal home visits and village sessions, ASHA (accredited social health activist) workers should prepare the family not just for birth, but also about the rules and regulations of the hospital, encourage discipline and respect of the HCPs. Hospital help desks and audio-visual materials displayed in the hospital can further reinforce these messages.  

Policy Support Is Key

Compassionate, empathetic and respectful maternity care has been included in India’s LaQshya guidelines and quality assurance mechanisms, but effective implementation varies widely. States must back guidelines with resources, monitoring, and accountability structures.

Khwaja Saadat Noor is a public health and development professional. He serves as the Bihar State Head of Office for UNFPA.  Amrita Misra is a medical doctor and public health professional. She provides strategic and technical inputs to organisations working on public health issues.  The views are personal.