Strengthening Teamwork and Respect (STAR): nurses’ perspectives and experiences of disrespectful maternity care in rural district hospitals in KwaZulu-Natal, South Africa

BACKGROUND: Disrespectful maternal care has been reported from women's perspectives, but less is known about how health workers understand these behaviours. To develop interventions, it is important to explore the drivers of disrespectful care from providers' perspectives. OBJECTIVE: To explore nurses' perspectives on disrespectful maternal care. METHODS: Semi-structured interviews were conducted with 18 nurses in maternity units in nine rural district hospitals in KwaZulu-Natal, South Africa, between April and August 2024. This was part of a continuous process evaluation for a participatory learning and action intervention called Strengthening Teamwork and Respect (STAR). One STAR champion and one team member were selected from each hospital. Interviews were recorded, transcribed, and thematically analysed using a reflexive thematic approach. RESULTS: Participants reflected on how STAR changed their perceptions and understanding of respectful care. Five themes were identified: limited understanding of disrespectful care; normalisation of disrespectful behaviours; justification of disrespectful care; blaming women for disrespectful care; and perceptions of disrespect in the community. Overt incidents of disrespectful care were reported to be commonplace, including rudeness, shouting and slapping women. Lack of dignity and privacy was also common. Nurses recognised these behaviours as unacceptable and unprofessional and offered several explanations, including peer pressure, stress, burnout, and a poor work environment. Some believed that harsh behaviour was sometimes necessary to ensure safe delivery, particularly when women were perceived as uncooperative. CONCLUSIONS: Normalisation of disrespectful care highlights the need for interventions that address the underlying culture and the organisational and contextual factors that support and sustain these behaviours.