1. Bernstein, Samantha L. PhD, RNC-OB, IBCLC

Article Content

Maternal morbidity and mortality are higher in the United States than in other similarly resourced nations. An estimated 60% of maternal deaths are preventable (Centers for Disease Control and Prevention, 2021). Black and American Indian/Alaskan Native women experience significantly higher rates of maternal morbidity and mortality than White, Hispanic, or Asian/Pacific Islander women. Women who are sexually minoritized, such as lesbian, bisexual, or queer experience decreased access to appropriate prenatal and intrapartum care. There is a direct connection between racism, disrespect, and mistreatment and poor maternal-fetal outcomes (Williams, 2021).


In response to these issues, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2022) developed an evidence-based clinical practice guideline on respectful maternity care (RMC). A diverse team of nurses conducted a comprehensive literature review, developed a framework for understanding RMC, and made evidence-based recommendations in six categories: awareness, mutual respect, shared decision-making and informed consent, autonomy, dignity, and accountability. A summary of the (AWHONN, 2022) clinical guideline is as follows.


Awareness requires that the nurse develops a personal understanding of their own birth philosophy and personal biases, acknowledging that all people have biases. The birth philosophy should be shared with women to support discussion and understanding. Mutual respect is an ongoing, collaborative process among patient, family, and care team through which we honor women's requests to the greatest extent possible, including preferences for support people, pain relief, and patient-centered communication. This process can be operationalized through encouraging patients to plan for appointments. Questionnaires provided prior to visits provide structure for discussion and help ensure questions are answered. Shared decision-making and informed consent are achieved by centering the birthing woman. Nurses should discuss all care options, provide high-quality care, and confirm informed consent or refusal. Structured care plans based on women's birth plans can support shared decision-making. Shared decision-making is enhanced when women are provided continuous support throughout labor and birth. This support improves the bond between the laboring person and caregiver leading to improved relationship and outcomes. Autonomy allows patients to make decisions free of coercive efforts to guide choices. By providing evidence-based options through a nonjudgmental lens, the nurse helps the woman to maintain control over her body care. Feeling in control can protect women from traumatic birth experiences (Koster et al., 2020). The promotion of dignity can be achieved through providing privacy, preferred clothing, and introducing all clinicians present with name and title. Nurses should maximize women's physical freedom during labor and birth, recognizing that movement improves outcomes as well as promoting dignity, autonomy, and sense of control. Patients' partners and support persons should be welcomed as members of the care team, rather than tolerated as necessary. This includes providing appropriate physical support for partners whenever possible, such as recliners and bedding for sleeping, meals, and access to shower and restrooms. Accountability by both individuals and institutions was deemed essential to RMC. Bedside handover promotes accountability across shifts and professional roles. Nurses and other team members must be educated about obstetric violence, including prevention of and response to such violence. Institutions must take responsibility when things do not go well and provide patients education about how to report mistreatment or abuse. A formal debrief after negative outcomes can develop accountability. Ongoing data collection and improvement activities also improve accountability.


There is a critical need to improve maternity care in the United States. These guidelines are one tool that nurses and institutions can adapt for their environment to promote and support RMC, which is essential to improve outcomes, trust in nurses, midwives, and physicians, and reduction in racial and ethnic disparities.




Association of Women's Health, Obstetric and Neonatal Nurses. (2022). Respectful maternity care framework and evidence-based clinical practice guideline. Journal of Obstetric, Gynecologic, and Neonatal Nursing. Advance online publication.[Context Link]


Centers for Disease Control and Prevention. (2021). Pregnancy mortality surveillance system.[Context Link]


Koster D., Romijn C., Sakko E., Stam C., Steenhuis N., Vries D., van Willigen I., Fontein-Kuipers Y. (2020). Traumatic childbirth experiences: Practice-based implications for maternity care professionals from the woman's perspective. Scandinavian Journal of Caring Sciences, 34(3), 792-799.[Context Link]


Williams D. R. (2021, May). Why discrimination is a health issue. Robert Wood Johnson Foundation.[Context Link]