Table 2 Summary of Barriers and Contextual Features at the Individual, Interpersonal, Organizational, and Community Levels

▪ Providers do not consider the decision to provide respectful care because they already believe they are providing respectful care or what they are expected to do

▪ Provider had a painful delivery and has attended many painful deliveries

▪ With experience provider has developed a “feel” for how care is provided

▪ Supervision and feedback focused on clinical treatment and health risks

▪ Training is focused on clinical treatment

▪ Clinical algorithms and guidelines, including visual cues in the facility do not provide clear guidelines for good care

▪ Pain is seen as a natural birth experience

▪ Providers do not consider the decision to provide respectful care explicitly since abuse and violence are normalized and therefore the default

▪ Provider experienced violence as a child as a form of discipline

▪ Actions of other providers reinforce the perception that maintaining control is paramount

▪ Training emphasizes need for rigid, forcefully delivered commands and interventions

▪ Providers decide not to provide respectful care since they believe they do not need to provide it

▪ Provider has never interacted with the client before delivery and client behaves erratically or does not follow instructions

▪ No serious consequences to providers who engage in disrespectful or abusive behavior

▪ Client appears to be low income or low status

▪ Providers decide not to provide respectful care consistently since they believe that the costs of providing it outweigh the gains

▪ Maternal or infant death results in an audit

▪ No salient information or feedback on the impact of respectful or disrespectful care on health outcomes

▪ Providers change their mind on providing respectful care when they believe that disrespectful care will assist their objectives

▪ Client does not follow instructions of provider