Submitted:
15 July 2026
Posted:
17 July 2026
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Abstract
Background: Respectful maternity care is recognized as a core component of high-quality maternal and newborn services, affirming women’s right to dignified, equitable, and person-centered care throughout pregnancy, childbirth, and the postnatal period. It goes beyond clinical safety to include emotional support, clear communication, respect for women’s autonomy, and protection from mistreatment. Family-centred maternal and newborn care complements this by actively involving women’s families and support networks, promoting shared decision-making and continuity of care from pregnancy through early neonatal life. Methods: A descriptive cross-sectional survey was conducted among midwives working in public maternity settings, using non-probability snowball sampling. Data was collected using a structured questionnaire that included demographic variables and a self-report checklist on antenatal, intrapartum, and postnatal support, as well as collaboration and support from healthcare professionals. Data was subsequently analyzed in SPSS Version 26 using descriptive statistics, exploratory factor analysis, and correlation. Results: Intrapartum support showed strong positive correlations with antenatal support (r = 0.555, p < .001) and immediate postpartum support (r = 0.529, p < .001), indicating significant associations. Similarly, human and safe care correlated positively with monitoring and interventions (r = 0.528, p < .001) and with immediate postpartum support (r = 0.559, p < .001). Conclusion: Enhancing support systems during the antenatal, intrapartum, postnatal, and early neonatal periods, together with strong professional collaboration and effective monitoring, can enhance the provision of respectful, high-quality, evidence-based care.
Keywords:
determinants
; evidence
; family-centered
; high-quality
; maternity care
; neonatal care
1. Introduction
Maternity care settings are part of a complex, challenging system that requires dynamic evidence-based practices (EBPs) [1]. Globally, the World Health Organization (WHO) emphasises that quality maternity care must be safe, effective, timely, efficient, equitable, woman- and family-centered [2]. Woman- and family-centered care cannot truly be considered inclusive unless women’s preferences, clinical requirements, and cultural contexts are fully integrated into the care provided. This global agenda is reinforced by the United Nations Sustainable Development Goals, particularly Goal 3 (Good Health and Well-being), which calls for strengthened health systems and equitable access to quality reproductive healthcare [3,4]. Achieving these targets requires empirical evidence to inform workforce planning, policy refinement, and targeted quality improvement interventions.
Empirical evidence from low- and middle-income countries, including Ethiopia, Tanzania, and Uganda, indicates that deficits in essential equipment, suboptimal remuneration of health personnel, and inadequate health system infrastructure constitute major impediments to the provision of high-quality maternity care [5,6,7]. Furthermore, the shortage of healthcare providers contributes to high caseloads, while inadequate resources and poor infrastructure worsen working conditions. Factors related to healthcare providers (HCPs), such as attitudes, knowledge, skills, and cultural sensitivity, also influence care, along with broader social, economic, and political determinants that affect maternal and newborn outcomes [6]. In such contexts, facility policies and standards are essential in promoting equity and improved outcomes [8]. Adverse working environments negatively impact HCPs, leading to dissatisfaction, burnout, and compromised care, whereas supportive environments and adequate staffing are associated with improved quality of care and better health outcomes [9,10]. Emotional support for women can be improved with a family-centered approach that involves trusted relatives or partners to enhance comfort and safety [11].
In this global and LMIC context, maternal and newborn health remain key priorities in South Africa. Although the country has made progress in reducing maternal mortality over the past two decades, preventable maternal and perinatal deaths continue to occur, particularly in the public healthcare sector, where most women access maternity services [12]. National maternal and neonatal death review reports consistently identify avoidable health system-related factors, including delays in recognition and management of complications, inadequate monitoring, and human resource constraints, as contributing factors to adverse outcomes [12]. Administrative factors, such as staff shortages, account for 20.5% of maternal deaths, reinforcing the need to examine facility-level and workforce-related determinants of care practices [13].
Like other LMICs, South Africa faces systemic constraints, including limited medical equipment and supplies and low pay for healthcare workers [12,14]. The working conditions for HCPs in public hospitals are a global concern, especially in LMICs [12,15]. The healthcare system consists of a profit-oriented private sector and a publicly funded sector that charges very low fees or is free of charge, resulting in significant disparities in the quality of care. Public healthcare institutions often have staff shortages and demanding working conditions, unlike the private sector. Women from low socioeconomic backgrounds rely heavily on these services, in which HCPs hold greater authority and women have less influence over decisions [16].
The South African public health sector comprises community health centers, district hospitals, regional hospitals, and tertiary hospitals [17]. Expertise and service capacity differ between levels, influencing care processes and outcomes. Limited resources also lead to underuse and strain on physical and human resources [9]. Social determinants of health reveal unequal access to care, while unfair power, financial, and resource-allocation dynamics deepen disparities [3]. Midwives are the main providers of care; they provide comprehensive antenatal, intrapartum, postnatal, and neonatal care, including early detection of complications and initiation of emergency interventions [18]. Their clinical decisions, adherence to guidelines, and professional practice directly affect maternal and neonatal outcomes. The Department of Health guidelines provide a framework for healthcare providers [19]. However, although the NDoH has developed national maternity care guidelines and policy frameworks, their implementation in public healthcare facilities is strongly influenced by contextual and systemic factors.
These include high patient loads, staff shortages, poor infrastructure, limited material and financial resources, organizational culture, leadership support, interprofessional collaboration, overall workload, and access to continuing professional development [20]. Despite global health priorities, LMICs' health systems face persistent challenges. This study investigated factors influencing maternity care practices from the perspectives of midwives at different levels of healthcare. Against this background, the purpose of this study was to determine the factors influencing maternity care practices among midwives in public healthcare facilities and to analyze the strength and direction of relationships between organizational, professional, and systemic factors and maternity care practices.
2. Materials and Methods
2.1. Setting and Participants
A cross-sectional quantitative survey explored factors influencing the delivery of respectful maternity care as perceived by public-sector midwives in South Africa. The study sample comprised health care workers employed in community health centers, district, regional, and tertiary hospitals, all of whom had one year of clinical experience after community service. The inclusion criteria were working at a public hospital and having at least 1 year of work experience after community service.
2.2. Ethical Approval
Before data collection, informed consent was obtained from all participants. They were provided with a clear explanation of the study's purpose and assured that their participation was entirely voluntary. Participants were informed of their right to withdraw from the study at any point without consequence. No personal identification was collected, and all data remained confidential and was used only for research purposes. The study was conducted in full compliance with the principles outlined in the Declaration of Helsinki.
2.3. Recruitment
Participants were recruited using Facebook, and a non-probability sampling method using the snowball technique was adopted using Facebook as a social networking site (SNS). A sample of 100 participants was sufficient to estimate a proportion with a ±10% margin of error at 95% confidence [21]. In the present study, however, an all-inclusive sampling strategy was employed, encompassing all 138 eligible midwives, of whom 41.46% completed the study.
2.4. Data Collection
Using the QuestionPro online survey platform, P.L. collected data under the supervision of C.S.M. and W.L. The introductory survey page explained the study’s purpose, noted that participation was voluntary, assured confidentiality, and stated the estimated completion time to support informed decisions.
Data were collected between August and November 2021 using a validated, pre-existing self-administered instrument, “Good Practices in Normal Childbirth” [22], which was adapted in consultation with the faculty librarian and administered to midwives to obtain information on the determinants of respectful maternity care within their respective healthcare facilities. The questionnaire consisted of five items: antenatal, intrapartum, postpartum, collaboration, and support from healthcare professionals. Items were evaluated using a six-point Likert-type scale comprising the following response categories: all the time, very often, sometimes, rarely, never, and not applicable.
2.5. Data Analysis
The Statistical Software Package version 26 was used to analyze data. The analysis comprised descriptive statistics, exploratory factor analysis, and correlation analysis. Responses on a Likert scale with six ratings: all the time, very often, sometimes, rarely, never, and not applicable. These were analyzed in consultation with the statistician.
3. Results
3.1. Demographic Characteristics of Participants
A total of 137 healthcare professionals participated in the study. Participants were drawn from different levels of healthcare facilities, with the largest proportion working in Community Health Centers (35.04%, n = 48), followed closely by Tertiary Hospitals (33.58%, n = 46). Regional Hospitals accounted for 20.44% (n = 28) of participants, while District Hospitals contributed the smallest proportion at 10.95% (n = 15).
The mean healthcare facility score was 2.53 (SD = 1.28, SE = 0.11; 95% CI: 2.31–2.74). This distribution indicates that participants were relatively evenly represented across the different levels of healthcare facilities, with slightly higher representation from Community Health Centers and Tertiary Hospitals.
Most participants reported having over 20 years of professional experience. (29.71%, n = 40). This was followed by those with 6 -10 years of experience (24.64%, n = 34). Participants with 1–5 years and 16–20 years of experience each represented 15.94% (n = 22) of the sample, while those with 11–15 years of experience accounted for 13.77% (n = 19).
The mean years-of-experience score was 3.19 (SD = 1.49, SE = 0.13), with a 95% confidence interval of 2.94 to 3.44. Overall, the findings suggest that the sample comprised a relatively experienced workforce, with nearly one-third of participants reporting more than two decades of professional experience.
3.2. Descriptive Statistics
Descriptive statistics are presented for the six scale items: antenatal care, intrapartum care, immediate postpartum care, collaboration, and professional healthcare support. The findings show varying levels of implementation of supportive maternity care practices across these domains, as reflected in the sub-scale variables. (Appendix A.1)
3.2.1. Antenatal Support Sub-Scale Variables
Six (6) subscale variables showed generally positive practices in some areas, with most respondents reporting that women are referred for further care when needed (86; 80.37%). However, gaps in patient-centred care were evident, particularly in women’s autonomy to have a chosen companion during antenatal visits, which was rarely allowed (n=23; 21.10%), indicating a negative aspect of care experience.
3.2.2. Intrapartum Support Sub-Scale Variables
Twenty (20) subscale variables demonstrated strong adherence to certain clinical standards. Informed consent was frequently practiced before invasive procedures (n=77; 76.24%), alongside routine use of a partograph to monitor labour progress (n=70; 70.30%). Some outdated evidence-based practices persisted, such as enemas during labour, which were rarely used (n=65; 64.36%), indicating only partial alignment with guidelines.
3.2.3. Postpartum Support Sub-Scale Variables
Four (4) subscale variables indicated that care was generally of high quality, with mother-newborn rooming-in commonly implemented (n=81; 84.38%), indicating strong support for maternal-newborn bonding and early attachment.
3.2.4. Collaboration Sub-Scale Variables
Eight subscale variables showed moderate but positive levels of interdisciplinary engagement. Consultation with senior clinicians was commonly reported (n=50; 55.56%), as was access to diagnostic and therapeutic services (n=48; 54.55%), indicating teamwork and access to adequate resources prevailed but could be enhanced.
3.2.5. Healthcare Professional Sub-Scale Variables
Factors showed generally positive institutional support. Across eight subscale variables, respondents reported good access to Department of Health guidelines and policies (n=60; 73.17%), indicating that most healthcare professionals are supported with standardized clinical protocols to guide practice and improve consistency of care.
Overall, while several key maternity care practices demonstrate strong compliance with guidelines, notable gaps remain in patient-centred antenatal care and consistent collaboration, highlighting areas for improvement in quality of maternity services.
3.3. Exploratory Factor Analysis
To assess the suitability of the data for exploratory factor analysis, the Kaiser–Meyer–Olkin (KMO) sampling adequacy measure was applied, with values interpreted as excellent (> 0.90), good (0.70–0.89), and mediocre (0.50–0.69) [23]. Oblimin rotation was applied to improve high item loads and reduce low item loads [24]. The authors further emphasize that factorial loadings greater than 0.30 in the pattern matrix are acceptable. A significant Bartlett’s test (p < .001) confirms sufficient item correlations for factor analysis. In this study, Bartlett’s test was significant (p < 0.01), and factorial loadings exceeded 0.30, indicating an adequate sample size, a good fit to the model, and well-correlated items. (Appendix A.2)
3.3.1. Antenatal Support Subscale
For one factor, four elements emerged, explaining 38.04% of the total variance. Although meaningful, this percentage is relatively low for a single factor in the social sciences; additional factors could have improved the construct. Cronbach's Alpha of 0.58 indicates moderate internal consistency.
3.3.2. Intrapartum Support Subscale
The analysis identified three underlying dimensions: human and safe care, intrapartum support, and monitoring and interventions, comprising 5, 6, and 9 items, respectively. Cronbach’s alpha coefficients of 0.80, 0.86, and 0.81 demonstrate good internal consistency, indicating that the items within each dimension reliably measure the intended constructs. Collectively, these factors explained 54.35% of the total variance, suggesting that the extracted model accounts for a substantial proportion of the variability in the data. This level of explained variance supports the adequacy of the factorial structure and indicates that these dimensions represent key components of quality intrapartum care.
3.3.3. Postpartum Support Subscale
The analysis extracted one factor comprising four items, which explained 49.48% of the total variance. This indicates that the factor accounts for a moderate proportion of the variability in the data, suggesting that it captures an important aspect of the underlying construct. However, Cronbach’s alpha coefficient of 0.56 is below the generally accepted threshold of 0.70, indicating low internal consistency. This finding suggests the items may not reliably measure the same construct, calling the scale’s reliability into question. The factor may therefore need refinement through revising, removing, or adding items to improve its psychometric properties for future use.
3.3.4. Collaboration Subscale
The analysis identified two underlying dimensions: multidisciplinary teams (5 items) and investigations/referrals (3 items). Cronbach’s alpha coefficients of 0.67 and 0.58 indicate moderate internal consistency, respectively, suggesting that while the items are reasonably related, there is room to improve the reliability of both subscales. Collectively, the two factors explained 51.91% of the total variance, indicating that they account for more than half of the variability in the dataset. This level of explained variance supports the empirical adequacy of the factorial structure and suggests that the identified dimensions meaningfully represent important aspects of collaboration in maternity care, although further refinement of the items may enhance the reliability and measurement precision of the instrument
3.3.5. Healthcare Professional Support Subscale
The analysis revealed two dimensions: competence (five items) and physical/medical resources (three items). Cronbach’s alpha coefficients were 0.72 and 0.70, indicating good internal consistency. Together, these two factors explained 68.77% of the total variance, indicating that they capture a substantial proportion of the variability in the data. This high variance supports the robustness of the factorial structure and indicates that competence and the availability of physical and medical resources are key dimensions of healthcare professional support. These findings provide evidence of a reliable and well-defined measurement model for assessing healthcare professional support within the study context.
3.4. Correlation Between the Level of Health Care and the Underlying Variables
Cohen provides effect size guidelines for correlation: small, medium, and large, with large effects considered “practically significant” [25]. Mean correlations among the nine construct variables ranged from 0.21 to 0.54, indicating practical significance for maternity care. Intrapartum support was higher at the tertiary level (mean = 3.17) than at the district level (mean = 2.54). Community health centers (CHCs) demonstrated a medium positive effect size compared to tertiary facilities (Cohen’s d = 0.56) and recorded the highest mean score (2.78). (Appendix A.3).
Humane and safe care was greater at the tertiary level (mean = 1.83) than at the district level (mean = 1.63). CHCs showed medium positive effect sizes relative to the tertiary (Cohen’s d = 0.53) and regional levels (Cohen’s d = 0.4 The CHCs with the highest mean were at the tertiary level (mean = 2.30). Monitoring and intervention activities were more frequent at the tertiary level (mean = 3.17). CHCs demonstrated substantial positive effect sizes relative to tertiary-level facilities (Cohen’s d = 0.66–0.82) and achieved the highest mean score (3.49). Multidisciplinary support was more prevalent at the district level (mean = 2.00) than at the tertiary level (mean = 1.79). CHCs showed a moderate association with district-level care (Cohen’s d = 0.40) and again recorded the highest mean score (2.21). Investigations and referrals were the most frequent at the tertiary level (mean = 2.52). CHCs were strongly associated with tertiary (Cohen’s d = 0.80) and regional levels (Cohen’s d = 0.66), with a mean of 2.29. Competence-related actions were more frequently reported at tertiary facilities (mean = 2.39). CHCs showed a medium effect size relative to tertiary care (Cohen’s d = 0.40) and a mean of 2.22. Overall, the observed variability across levels of care underscores the greater degree of specialization and complexity characteristic of tertiary healthcare services.
3.5. Correlation Between the Underlying Variables and Years of Experience
Pearson’s product-moment correlation coefficient was used to assess the direction and magnitude of the associations among the construct variables [24]. The correlation was classified as weak (r = 0.10), moderate (r = 0.30), and strong (r = 0.50) [26]. (Appendix A.4).
There was a strong positive correlation between intrapartum support and antenatal support (r = 0.555, p < .001). Moderate positive correlations were observed between humane and safe care and intrapartum support (r = 0.484, p < .001), and between monitoring and interventions and humane and safe care (r = 0.528, p < .001). Immediate postpartum support demonstrated moderate positive correlations with antenatal support (r = 0.409, p < .001) and strong positive correlations with intrapartum support (r = 0.509, p < .001) and humane and safe care (r = 0.559, p < .001).
Competence, along with investigations and referrals involving multidisciplinary support, presented moderate positive correlations (r = 0.458 and r = 0.489, respectively, both p < .001). Multidisciplinary support also showed moderate positive correlations with humane and safe care (r = 0.368, p < .001), antenatal support (r = 0.331, p < .001), intrapartum support (r = 0.324, p < .001), and humane and safe care (r = 0.395, p < .001). The moderate-to-strong positive correlations suggest that increases in one variable were generally associated with increases in related constructs.
Negative correlations were identified between intrapartum support and years of experience (r = -0.211, p = 0.035) and between physical resources and years of experience (r = -0.217, p = 0.048), indicating that as years of experience increased, these variables tended to decrease.
4. Discussion
The study identified nine determinants that midwives perceive as shaping respectful and high-quality maternity care: antenatal support, intrapartum support, humane and safe care, monitoring and interventions, immediate postpartum support, multidisciplinary support, investigations and referral, competence, and physical and medical resources. Each can improve or worsen the quality of care. In antenatal care, referrals for further management were common, supporting continuity of care and improving maternal health outcomes. Similar findings showed that effective support and continuity of care lead to better maternal and neonatal outcomes and improved maternal experiences. [27]. However, the limited freedom for women to have a chosen companion during antenatal visits highlights persistent gaps in woman-centred care. Evidence from the WHO emphasizes that companionship during maternity care provides emotional support, improves women’s childbirth experiences, and promotes respectful care practices [2]. Studies [27,28] demonstrated that companionship during maternity care improves emotional support, women’s satisfaction with childbirth experiences, and respectful maternity care practices. Similarly, Mekonen et al. reported that healthcare providers acknowledged the positive contribution of labor companionship to maternal well-being and quality care [29].
During intrapartum care, obtaining informed consent and plotting the partograph were commonly practiced, demonstrating adherence to respectful and evidence-based maternity care standards. These findings are consistent with the study [32], which reported that appropriate use of the partograph supports monitoring of labor progress and early identification of complications, thereby improving maternal and neonatal outcomes. Furthermore, the study [31] emphasized that respectful maternity care practices, including communication and consent, are essential for preserving women’s dignity and autonomy during childbirth. The reported non-use of enemas during labor also reflects current evidence-based maternity practices, as routine enemas are no longer recommended because of limited clinical benefit. WHO recommendations discourage routine enemas because they provide minimal clinical benefit and may increase discomfort for women [2].
Postpartum care practices were positive, particularly regarding rooming-in for mothers and newborns. This finding aligns with a study [32] that showed that early and continuous mother–newborn contact promotes maternal bonding, improves breastfeeding initiation, and enhances neonatal adaptation. The WHO and UNICEF Baby-Friendly Hospital Initiative guidelines also recommend rooming-in as a key component of quality postpartum care [33]. In addition, rooming-in supports a family-centred care approach by encouraging the active involvement of family members in the care of the mother and newborn, strengthening parental confidence, facilitating shared caregiving, and fostering a supportive environment during the postnatal period. Such practices are important components of quality postpartum care and contribute to improved maternal and neonatal outcomes.
Institutional support factors showed that consultation with senior clinicians, accessibility to diagnostic services, and availability of departmental guidelines were commonly reported, suggesting supportive clinical environments and strengthened clinical governance. Similar findings indicated that supportive institutional systems and adherence to standardized guidelines improve the provision of respectful and evidence-based maternity care [31]. Access to clinical guidelines and collaboration with senior clinicians may therefore enhance healthcare providers’ confidence, consistency in decision-making, and overall quality of maternal healthcare services. Guidelines should include individualized and culturally sensitive care for women.
Infrastructure, human resources, and medical resources were identified as key enablers of high-quality care [34]. Women need skilled and compassionate providers working within a multidisciplinary framework to ensure optimal maternal and neonatal outcomes [35]. The role of current EBPs is to ensure good maternity practices that uphold women’s autonomy and cultural sensitivity. WHO advocates that all women should have a positive facility experience [2]. Throughout the maternity period, women require a comprehensive assessment to detect needs or risks, scheduled follow-up, and referral to specialized care when necessary [17]. These constructs collectively shape the quality of maternal care. Although access to quality care in LMICs is challenging, improving quality requires equal redistribution of resources, policy reform, and innovation [2].
At the tertiary level of healthcare, monitoring and intervention actions were frequent, with large effects (0.66, 0.72, 0.82) indicating practical significance. This level provides highly specialized obstetric services, contributing to the high frequency of interventions. However, this may reflect unwarranted use of medical procedures during childbirth. Similarly, a study [36] found frequent use of artificial membrane rupture, epidural anaesthesia, and episiotomy, which can cause infection, unnecessary pain, and discomfort, and illustrate the medicalization of birth. The availability of technological interventions often leads to unnecessary procedures such as episiotomy and caesarean section [37]. The authors therefore advocate the restrictive use of medical interventions to prevent medicalization of a physiological process that usually does not require routine intervention.
Activities related to diagnostic investigations and patient referrals were much more frequent in tertiary facilities, with a large effect size (Cohen’s d = 0.80) compared to other levels of care. This indicates a practically significant difference in the delivery of care. Because tertiary hospitals provide highly specialized services, they receive many referrals from regional and district hospitals [19]. Similarly, actions related to humane and safe care were most frequent at tertiary facilities, with a medium effect size (d = 0.53). This finding might be due to the diverse skills and specialization of HCPs at this level [17]. Competence-related actions were also more frequent in tertiary facilities (medium effect size, d = 0.40).
At the district level, limited skills likely explain the higher frequency of multidisciplinary support (medium effect size, d = 0.40), underscoring the need for consultation and collaboration across levels of care to optimize patient outcomes. Multidisciplinary teams, supervision, and transparent evaluation systems were found to support an efficient work environment [6], while ongoing skills development and up-to-date EBPs further promote optimal care [37].
This study examined how years of experience relate to antenatal support, intrapartum support, humane and safe care, monitoring and intervention, immediate postpartum care, multidisciplinary support, investigations and referrals, and competence and physical resources. Previous research in LMICs [6,38,39] identified provider competence, resource availability, and physical infrastructure as key determinants of suboptimal care. Studies [40,41] argue that these systemic issues must be addressed through governance and policy to ensure equitable and high-quality maternity care. In this study, correlation analysis showed that eight factors were statistically significant at the 0.01 level (two-tailed). Years of experience showed weak negative correlations with intrapartum support (r = −0.211, p = .035) and physical resources (r = −0.217, p = .048), indicating that more experienced midwives reported slightly lower levels of both. These relationships are statistically significant, suggesting that the patterns are unlikely to be due to random chance.
Reduced intrapartum support among more experienced midwives may reflect staff shortages: Higher workloads limit the support they can provide. Other studies similarly link lower use of physical resources with scarcity [6,38,39]. These patterns conflict with the WHO recommendations for continuous emotional and physical intrapartum support and birth companion of the woman’s choice [2]. Furthermore, resource scarcity is a major challenge in LMICs, affecting many aspects of care and requiring policy changes, more funding, and innovative strategies. In this study, several factors were highlighted as having practical implications for the quality of maternal care and therefore warrant close monitoring, evaluation, and corrective action.
5. Conclusions
The study shows that maternity care practices among midwives in public facilities in South Africa are shaped by organizational, professional, environmental, and systemic factors. Organizational elements, leadership, staffing, resources, institutional culture, and policy implementation strongly influence care. The knowledge, skills, and attitudes of midwives towards evidence-based practice and ongoing training are influenced by adherence to guidelines. Environmental and systemic conditions, infrastructure, workload, referral systems, and governance further impact the ability to provide optimal care.
These determinants are strongly intercorrelated, with all subscales significantly shaping maternity care practices. Positive correlations indicate that these factors jointly influence care in public maternity settings, although the findings are not generalizable to other contexts. If not addressed, these factors can undermine the quality of care, underscoring the need for adequate funding, resources, policy frameworks, multidisciplinary collaboration, and alignment with current evidence-based guidelines. Addressing them at all levels of care is essential for synergy, better outcomes, and equitable, dignified, efficient, and effective maternal care. Improving care in public facilities, therefore, requires integrated strategies that target organizational structures, professional development, and systemic reforms, rather than focusing solely on individual providers.
Author Contributions
Conceptualization, P.L.; methodology, P.L; software, P.L.; C.S.M. and W.L.; formal analysis, P.L.; investigation, P.L; resources, P.L.; data curation, P.L.; writing—original draft preparation, P.L.; writing—review and editing, P.L.; supervision, C.S.M. and W.L.; project administration, P.L.; funding acquisition, C.S.M. All authors have read and agreed to the published version of the manuscript.
Funding
Thuthuka Grant, grant number TTK13070720678. North West University paid for the APC.
Institutional Review Board Statement
The study was conducted in full compliance with the principles outlined in the Declaration of Helsinki for studies involving humans. Ethical approval for the study was granted by the North-West University Health Research Ethics Committee, approval number NWU-00503-19-A1 and date of approval 3 February 2021.
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The data presented in this study are available from the corresponding author upon reasonable request. Data access is subject to a two-year embargo in accordance with the applicable institutional policies and procedures.
Acknowledgments
Thank you to Professor S. Ellis for statistical assistance.
Conflicts of Interest
The authors declare no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| CHC | Community Health Center |
| EBP | Evidence-Based Practice |
| HCP | Health Care Professionals |
| ICM | International Confederation of Midwives |
| LIMC | Low- and Middle-Income Countries |
| NDoH | National Department of Health |
| SDG | Sustainable Development Goals |
| UN | United Nations |
| UNICEF | United Nations Children’s Emergency Fund |
| UNFP | United Nations Population Fund |
| WHO | World Health Organization |
Appendix A
Appendix A.1. Tables: Descriptive Statistics
Table 1.
Antenatal support-related factors.
| Antenatal support related items | All the time | Very often | Sometimes | Rarely | Never | N/A | Total | |
| AS3: women receive all components of basic antenatal care | Count | 71 | 25 | 16 | 4 | 0 | 0 | 116 |
| Row N % | 61,21 | 21,55 | 13,79 | 3,45 | 0,00 | 0,00 | 100% | |
| AS4: accessibility to other antenatal information through mom-connect | Count | 51 | 26 | 21 | 2 | 4 | 7 | 111 |
| Row N % | 45,95 | 23,42 | 18,92 | 1,80 | 3,6 | 6,31 | 100% | |
| AS5: freedom to have a chosen companion present during antenatal visits | Count | 38 | 15 | 24 | 23 | 6 | 3 | 109 |
| Row N % | 34,86 | 13,76 | 22,02 | 21,10 | 5,50 | 2,75 | 100% | |
| AS6: women are referred for further care when the need arises | Count | 86 | 14 | 3 | 0 | 2 | 2 | 107 |
| Row N % | 80,37 | 11,08 | 2,80 | 0,00 | 1,87 | 1,87 | 100% | |
| AS7: availability of individual consulting space to ensure confidentiality and privacy | Count | 76 | 12 | 11 | 8 | 1 | 0 | 108 |
| Row N % | 70,37 | 11,11 | 10,19 | 7,41 | 0,93 | 0,00 | 100% | |
Note: (AS) antenatal support.
Table 2.
Intrapartum support related factors.
| Intrapartum support related items | All the time | Very often | Sometimes | Rarely | Never | N/A | Total | |
| HSC8: availability of basic intrapartum care package for women | Count | 62 | 22 | 7 | 4 | 0 | 5 | 100 |
| Row N % | 62,00 | 22,00 | 7,00 | 4,00 | 0,00 | 5,00 | 100% | |
| IS9: availability of individual space to ensure confidentiality and privacy to women | Count | 59 | 21 | 11 | 3 | 3 | 2 | 99 |
| Row N % | 59,60 | 21,21 | 11,11 | 3,03 | 3.03 | 2,02 | 100% | |
| HSC10: provision of drink and food to low risk women | Count | 53 | 23 | 6 | 6 | 3 | 8 | 99 |
| Row N % | 53,54 | 23,23 | 6,06 | 6,06 | 3,03 | 8,08 | 100% | |
| MI11: monitoring of the foetal heart rate half hourly during the active phase | Count | 43 | 26 | 17 | 8 | 2 | 4 | 100 |
| Row N % | 43,00 | 26,00 | 17,00 | 8,00 | 2,00 | 4,00 | 100% | |
| MI12: give enema during labour | Count | 1 | 2 | 6 | 15 | 65 | 12 | 101 |
| Row N % | 0,99 | 1,98 | 5,94 | 14,85 | 64,36 | 11,88 | 100% | |
| MI13: augment labour with oxytocin infusion | Count | 11 | 18 | 31 | 19 | 12 | 7 | 101 |
| Row N % | 10,89 | 17,82 | 34,65 | 15,84 | 13,86 | 6,93 | 100% | |
| MI14: administration of intravenous fluids for low risk women | Count | 14 | 18 | 31 | 19 | 12 | 7 | 101 |
| Row N % | 13,86 | 17,82 | 30,69 | 18,81 | 11,88 | 6,93 | 100% | |
| HSC15: use of non-pharmacological pain relief methods during labour | Count | 36 | 23 | 22 | 14 | 2 | 4 | 101 |
| Row N % | 35,64 | 22,77 | 21,78 | 13,86 | 1,98 | 3,96 | 100% | |
| IS16: freedom to have a birth companion of choice by women | Count | 31 | 11 | 21 | 17 | 11 | 8 | 99 |
| Row N % | 31,31 | 11,11 | 21,21 | 17,17 | 11,11 | 8,08 | 100% | |
| IS17: provide one-to-one care to women | Count | 41 | 14 | 15 | 19 | 8 | 2 | 99 |
| Row N % | 41,41 | 14,14 | 15,15 | 19,19 | 8,08 | 2,02 | 100% | |
| MI18: monitor the progress of labour using the partogram | Count | 71 | 16 | 7 | 2 | 1 | 4 | 101 |
| Row N % | 70,30 | 15,84 | 6,93 | 1,98 | 0,99 | 3,96 | 100% | |
| HSC19: provide informed consent to the women prior invasive procedures | Count | 77 | 13 | 2 | 2 | 1 | 6 | 101 |
| Row N % | 76,24 | 12,87 | 1,98 | 1,98 | 0,99 | 5,95 | 100% | |
| IS20: freedom to adopt position of choice during labour/childbirth by women | Count | 23 | 16 | 26 | 17 | 14 | 5 | 101 |
| Row N % | 22,77 | 15,84 | 25,74 | 16,83 | 13,86 | 4,95 | 100% | |
| MI21: use of ordinary beds for normal childbirth | Count | 24 | 14 | 19 | 15 | 24 | 5 | 101 |
| Row N % | 23,76 | 13,86 | 18,81 | 14,85 | 23,76 | 4,95 | 100% | |
| MI22: perform episiotomy | Count | 1 | 7 | 51 | 30 | 4 | 4 | 97 |
| Row N % | 1,03 | 7,22 | 52,58 | 30,93 | 4,12 | 4,12 | 100% | |
| MI23: perform artificial rupture of membranes | Count | 3 | 14 | 46 | 26 | 4 | 5 | 98 |
| Row N % | 3,03 | 14,29 | 46,94 | 26,53 | 4,08 | 5,10 | 100% | |
| MI24: perform assisted births | Count | 3 | 10 | 34 | 30 | 13 | 8 | 98 |
| Row N % | 3,06 | 10,20 | 34,69 | 30,61 | 13,27 | 8,16 | 100% | |
| HSC25: encourage spontaneous bearing down during the second stage without interference | Count | 43 | 30 | 13 | 7 | 2 | 3 | 98 |
| Row N % | 43,88 | 30,61 | 13,27 | 7,14 | 2,04 | 3,06 | 100% | |
| IS26: allow partner/husband to be present during labour | Count | 28 | 7 | 21 | 18 | 15 | 7 | 96 |
| Row N % | 29,17 | 7,29 | 21,88 | 18,75 | 15,63 | 7,29 | 100% | |
| IS27: provide information on progress of labour to partner/husband | Count | 33 | 15 | 23 | 14 | 3 | 6 | 94 |
| Row N % | 35,11 | 15,96 | 24,47 | 14,89 | 3,19 | 6,38 | 100% | |
| Count | ||||||||
Note: (HSC) humane and safe care, (IS) intrapartum support, (MI) monitoring and interventions.
Table 3.
Postpartum support related factors.
| Postpartum support related items | All the time | Very often | Sometimes | Rarely | Never | N/A | Total | |
| IPS28: encourage skin-to-skin contact between new mother and newborn within the first hour of childbirth | Count | 73 | 14 | 7 | 1 | 0 | 1 | 96 |
| Row N % | 76,04 | 14,58 | 7,29 | 1,04 | 0,00 | 1,04 | 100% | |
| IPS29: assist the new mother with breastfeeding when necessary | Count | 73 | 15 | 6 | 2 | 0 | 0 | 96 |
| Row N % | 76,04 | 15,63 | 6,25 | 2,08 | 0,00 | 0,00 | 100% | |
| IPS30: rooming-in for the new mother and newborn | Count | 81 | 9 | 5 | 0 | 0 | 1 | 96 |
| Row N % | 84,38 | 9,38 | 5,21 | 0,00 | 0,00 | 1,04 | 100% | |
| IPS31: provide the family with private time to bond | Count | 39 | 13 | 20 | 18 | 2 | 4 | 96 |
| Row N % | 40,63 | 13,54 | 20,83 | 18,75 | 2,08 | 4,17 | 100% | |
Note: (IPS) Immediate postpartum support.
Table 4.
Collaboration related factors.
| Collaboration related items | All the time | Very often | Sometimes | Rarely | Never | N/A | Total | |
| MDT32: consultation for clinical decisions is made with a senior clinician | Count | 50 | 23 | 11 | 4 | 2 | 0 | 90 |
| Row N % | 55,56 | 25,56 | 12,22 | 4,44 | 2,22 | 0,00 | 100% | |
| MDT33: participation of all health professionals in maternal mortality meetings to discuss improvements in patient care | Count | 44 | 16 | 17 | 8 | 4 | 1 | 90 |
| Row N % | 48,89 | 17,78 | 18,89 | 8,89 | 4,44 | 1,11 | 100% | |
| MDT34: accessibility to other diagnostic services and therapeutic procedures that are not available at the facility | Count | 48 | 11 | 18 | 5 | 2 | 4 | 88 |
| Row N % | 54,55 | 12,50 | 20,45 | 5,68 | 2,27 | 4,55 | 100% | |
| IR35: accessibility to electronic patient information for continuity of care | Count | 27 | 10 | 21 | 13 | 14 | 4 | 89 |
| Row N % | 30,34 | 11,24 | 23,60 | 14,61 | 15,73 | 4,49 | 100% | |
| MDT36: sharing of latest evidence-based information between doctors and midwives | Count | 31 | 23 | 18 | 14 | 2 | 0 | 88 |
| Row N % | 35,23 | 26,14 | 20,45 | 15,91 | 2,27 | 0,00 | 100% | |
| IR37: minimum medical interventions for low risk women | Count | 44 | 21 | 11 | 7 | 2 | 0 | 87 |
| Row N % | 50,57 | 24,14 | 12,64 | 8,05 | 2,30 | 2,30 | 100% | |
| MDT38: teamwork between doctors and midwives prevails | Count | 45 | 20 | 16 | 4 | 0 | 1 | 86 |
| Row N % | 52,33 | 23,26 | 18,60 | 4,65 | 0 | 1,16 | 100% | |
| IR39: referred women come with maternity baseline investigations done | Count | 33 | 27 | 21 | 2 | 1 | 2 | 86 |
| Row N % | 38,37 | 31,40 | 24,42 | 2,33 | 1,16 | 2,33 | 100% | |
Note: (MDT) Multidisciplinary team; (IR) Investigations and referral.
Table 5.
Healthcare professional support related factors.
| Support related items | All the time | Very often | Sometimes | Rarely | Never | N/A | Total | |
| PMR40: sufficient beds to accommodate the women cared for daily | Count | 23 | 16 | 23 | 7 | 12 | 3 | 84 |
| Row N % | 27,38 | 19,05 | 27,38 | 8,33 | 14,29 | 3,57 | 100% | |
| PMR41: availability of alternative space for women when the unit is full | Count | 16 | 14 | 17 | 17 | 15 | 4 | 83 |
| Row N % | 19,28 | 16,87 | 20,48 | 20,48 | 18,07 | 4,82 | 100% | |
| PMR42: availability of medical supplies, equipment and medicines | Count | 33 | 27 | 17 | 4 | 1 | 1 | 83 |
| Row N % | 39,76 | 32,53 | 20,40 | 4,82 | 1,20 | 1,20 | 100% | |
| C43: evaluating accessibility of care provided to women through questionnaires | Count | 20 | 10 | 28 | 12 | 11 | 1 | 82 |
| Row N % | 24,39 | 12,20 | 34,15 | 14,63 | 13,41 | 1,22 | 100% | |
| C44: cultural sensitivity towards women | Count | 38 | 19 | 13 | 7 | 5 | 0 | 82 |
| Row N % | 46,34 | 23,17 | 15,85 | 8,54 | 6,10 | 0,00 | 100% | |
| C45: availability of Department of health guidelines and policies | Count | 60 | 11 | 11 | 0 | 0 | 0 | 82 |
| Row N % | 73,17 | 13,41 | 13,41 | 0,00 | 0,00 | 0,00 | 100% | |
| C46: availability of opportunities to attend continuous professional development workshops/training | Count | 25 | 20 | 26 | 10 | 1 | 0 | 82 |
| Row N % | 30,49 | 24,39 | 31,71 | 12,20 | 1,22 | 0,00 | 100% | |
| C47: in-house training opportunities | Count | 25 | 22 | 23 | 7 | 5 | 0 | 82 |
| Row N% | 30,49 | 26,83 | 28,05 | 8,54 | 6,10 | 0,00 | 100% | |
Note: (PMR) Physical and medical resources; (C) Competence.
Appendix A.2. Tables: Exploratory Factor Analysis
Table 1.
Antenatal support.
| Item number | Item | Component |
| Antenatal support | ||
| 7 | Availability of individual consulting space to ensure confidentiality and privacy | 0,735 |
| 3 | Women receive all components of basic antenatal care | 0,716 |
| 5 | Freedom to have a chosen companion present during antenatal visits | 0,703 |
| 6 | Women are referred for further care when the need arises | 0,471 |
| Extraction Method: Principal Component Analysis. a. One Component Extracted. | ||
Table 2.
Intrapartum support.
| Components | ||||
| Item number | Item | Humane and safe care | Intrapartum support | Monitoring and intervention |
| 19 | Obtain informed consent from women before procedures | 0,812 | ||
| 25 | Encourage spontaneous bearing down during the second stage without interference | 0,766 | ||
| 10 | Provision of drink and food to low-risk women | 0,705 | ||
| 15 | Use of non-pharmacological pain relief methods during labour | 0,511 | ||
| 8 | Availability of basic intrapartum care package for women | 0,406 | -0,353 | 0,370 |
| 26 | Allow partner/husband to be present during labour | -0,876 | ||
| 16 | Freedom to have a birth companion of choice by women | -0,857 | ||
| 27 | Provide information on the progress of labour to the partner/husband | -0,826 | ||
| 17 | Provide one-to-one care to women | -0,641 | ||
| 20 | Freedom to adopt a position of choice during labour/childbirth by women | 0,296 | -0,601 | |
| 9 | Availability of individual space to ensure confidentiality and privacy for women | 0,298 | -0,374 | |
| 11 | Monitoring of the foetal heart rate half-hourly during the active phase | -0,428 | 0,414 | |
| 22 | Perform episiotomy | 0,896 | ||
| 23 | Perform artificial rupture of membranes | 0,837 | ||
| 12 | Give enema during labour | -0,364 | 0,667 | |
| 13 | Augment labour with oxytocin infusion | 0,351 | 0,641 | |
| 14 | Administration of intravenous fluids for low-risk women | 0,586 | ||
| 24 | Perform assisted births | 0,543 | ||
| 18 | Monitor the progress of labour using the partogram | 0,468 | ||
| 21 | Use of ordinary beds for normal childbirth | 0,356 | ||
| Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. a. One Component Extracted. | ||||
Table 3.
Immediate postpartum support.
| Component | ||
| Item number | Item | Immediate postpartum care |
| 30 | Rooming-in for the new mother and new-born | 0,824 |
| 28 | Encourage skin-to-skin contact between new mother and new-born within the first hour of childbirth | 0,822 |
| 29 | Assist the new mother with breastfeeding when necessary | 0,612 |
| 31 | Provide the family with private time to bond | 0,501 |
| Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. a. One Component Extracted. | ||
| Collaboration | ||
Table 4.
Collaboration.
| Components | |||
| Item number | Item | Multidisciplinary team | Investigations and referral |
| 33 | Participation of all health professionals in maternal mortality meetings to discuss improvements in patient care | 0,817 | |
| 32 | Consultation for clinical decisions is made with a senior clinician | 0,802 | |
| 36 | Sharing of the latest evidence-based information between doctors and midwives | 0,633 | |
| 34 | Accessibility to other diagnostic services and therapeutic procedures that are not available at the facility | 0,617 | |
| 38 | Teamwork between doctors and midwives prevails | 0,480 | 0,419 |
| 39 | Referred women come with maternity baseline investigations done | 0,747 | |
| 35 | Accessibility to electronic patient information for continuity of care | 0,714 | |
| 37 | Minimum medical interventions for low-risk women | 0,573 | |
| Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. a. One component extracted. | |||
Table 5.
Healthcare professional support.
| Components | |||
| Item number | Item | Competence | Physical and medical support |
| 46 | Availability of opportunities to attend continuous professional development workshops/training | 0,782 | |
| 43 | Evaluating accessibility of care provided to women through questionnaires | 0,749 | |
| 45 | Availability of Department of Health guidelines and policies | 0,719 | |
| 47 | In-house training opportunities | 0,639 | |
| 44 | Cultural sensitivity towards women | 0,540 | |
| 40 | Sufficient beds to accommodate the women cared for daily | 0,854 | |
| 41 | Availability of alternative space for women when the unit is full | 0,792 | |
| 42 | Availability of medical supplies, equipment, and medicines | 0,696 | |
| Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. a. Rotation Converged In 5 Iterations. | |||
Appendix A.3. Tables: Correlation Between the Level of Health Care and the Underlying VariablesAppendix A.4. Tables: Correlation Between the Underlying Variables and Years of Experience
| Factors | Level of healthcare facility | Number | Mean | Std. Deviation |
Anova p-value |
Cohen's d effect sizes | ||
| CHC | CHC with | CHC with | ||||||
| Antenatal support | Community Health Centre (CHC) | 39 | 1,69 | 0,62 | ||||
| District hospital | 14 | 1,93 | 0,63 | 0,37 | ||||
| Regional hospital | 23 | 1,98 | 0,81 | 0,35 | 0,06 | |||
| Tertiary hospital | 36 | 1,72 | 0,81 | 0,03 | 0,25 | 0,32 | ||
| Total | 112 | 1,79 | 0,73 | 0,391 | ||||
| Intrapartum support | Community Health Centre (CHC) | 35 | 2,78 | 1,46 | ||||
| District hospital | 14 | 3,17 | 0,53 | 0,27 | ||||
| Regional hospital | 17 | 2,84 | 1,16 | 0,04 | 0,28 | |||
| Tertiary hospital | 32 | 2,54 | 1,12 | 0,17 | 0,56 | 0,26 | ||
| Total | 98 | 2,77 | 1,20 | 0,426 | ||||
| Humane and safe care | Community Health Centre (CHC) | 36 | 2,30 | 1,28 | ||||
| District hospital | 14 | 1,83 | 0,76 | 0,37 | ||||
| Regional hospital | 17 | 1,74 | 0,52 | 0,44 | 0,13 | |||
| Tertiary hospital | 33 | 1,63 | 0,50 | 0,53 | 0,27 | 0,21 | ||
| Total | 100 | 1,92 | 0,93 | 0,016 | ||||
| Monitoring and Interventions | Community Health Centre (CHC) | 36 | 3,49 | 1,08 | ||||
| District hospital | 14 | 3,17 | 0,54 | 0,30 | ||||
| Regional hospital | 17 | 3,16 | 0,37 | 0,31 | 0,01 | |||
| Tertiary hospital | 33 | 2,78 | 0,46 | 0,66 | 0,72 | 0,82 | ||
| Total | 100 | 3,16 | 0,79 | 0,002 | ||||
| Immediate postpartum support | Community Health Centre (CHC) | 30 | 1,55 | 0,79 | ||||
| District hospital | 13 | 1,58 | 0,55 | 0,03 | ||||
| Regional hospital | 17 | 1,66 | 0,57 | 0,14 | 0,15 | |||
| Tertiary hospital | 33 | 1,62 | 0,57 | 0,09 | 0,08 | 0,07 | ||
| Total | 93 | 1,60 | 0,64 | 0,942 | ||||
| Multidisciplinary support | Community Health Centre (CHC) | 28 | 2,21 | 1,05 | ||||
| District hospital | 13 | 1,79 | 0,64 | 0,40 | ||||
| Regional hospital | 15 | 1,90 | 0,77 | 0,30 | 0,15 | |||
| Tertiary hospital | 32 | 2,00 | 0,96 | 0,20 | 0,22 | 0,10 | ||
| Total | 88 | 2,02 | 0,92 | 0,518 | ||||
| Investigations and referrals | Community Health Centre (CHC) | 28 | 2,29 | 1,07 | ||||
| District hospital | 13 | 2,02 | 0,75 | 0,25 | ||||
| Regional hospital | 15 | 2,52 | 0,64 | 0,22 | 0,66 | |||
| Tertiary hospital | 32 | 1,97 | 0,68 | 0,29 | 0,06 | 0,80 | ||
| Total | 88 | 2,17 | 0,84 | 0,155 | ||||
| Competence | Community Health Centre (CHC) | 26 | 2,22 | 0,87 | ||||
| District hospital | 12 | 2,18 | 0,49 | 0,06 | ||||
| Regional hospital | 15 | 2,39 | 0,62 | 0,19 | 0,34 | |||
| Tertiary hospital | 29 | 2,03 | 0,88 | 0,22 | 0,16 | 0,40 | ||
| Total | 82 | 2,18 | 0,78 | 0,548 | ||||
| Physical and medical resources | Community Health Centre (CHC) | 26 | 2,83 | 1,23 | ||||
| District hospital | 13 | 2,51 | 0,95 | 0,26 | ||||
| Regional hospital | 15 | 2,64 | 0,79 | 0,15 | 0,14 | |||
| Tertiary hospital | 28 | 2,49 | 1,19 | 0,28 | 0,02 | 0,13 | ||
| Total | 82 | 2,63 | 1,10 | 0,687 | ||||
| Factors | Pearson correlation | Years of experience | AS | IS | HSC | MI | IPS | MDT | IR | C | PR | |
| Antenatal Support | Pearson's correlation | -0,015 | 1 | .555** | .278** | 0,044 | .409** | 0,128 | .331** | .368** | .436** | |
| Sig. (2-tailed) | 0,874 | 0,000 | 0,005 | 0,663 | 0,000 | 0,230 | 0,002 | 0,001 | 0,000 | |||
| N | 115 | 116,00 | 100 | 102 | 102 | 95 | 89 | 89 | 83 | 83 | ||
| Intrapartum support | Pearson's correlation | -.211* | .555** | 1 | .484** | .264** | .529** | 0,135 | .324** | .327** | .483** | |
| Sig. (2-tailed) | 0,035 | 0,00 | 0,000 | 0,008 | 0,000 | 0,206 | 0,002 | 0,003 | 0,000 | |||
| N | 100 | 100,00 | 101 | 101 | 101 | 95 | 89 | 89 | 83 | 83 | ||
| Humane and safe care | Pearson's correlation | -0,171 | .278** | .484** | 1 | .528** | .559** | .368** | .395** | .386** | .414** | |
| Sig. (2-tailed) | 0,085 | 0,00 | 0,000 | 0,000 | 0,000 | 0,000 | 0,000 | 0,000 | 0,000 | |||
| N | 102 | 102,00 | 101 | 103 | 103 | 96 | 90 | 90 | 84 | 84 | ||
| Monitoring and Interventions | Pearson's correlation | -0,015 | 0,04 | .264** | .528** | 1 | .350** | .292** | .252* | 0,005 | 0,175 | |
| Sig. (2-tailed) | 0,879 | 0,66 | 0,008 | 0,000 | 0,000 | 0,005 | 0,017 | 0,966 | 0,111 | |||
| N | 102 | 102,00 | 101 | 103 | 103 | 96 | 90 | 90 | 84 | 84 | ||
| Immediate postpartum Support |
Pearson's correlation | 0,004 | .409** | .529** | .559** | .350** | 1 | .256* | .493** | .321** | .424** | |
| Sig. (2-tailed) | 0,970 | 0,00 | 0,000 | 0,000 | 0,000 | 0,015 | 0,000 | 0,003 | 0,000 | |||
| N | 95 | 95,00 | 95 | 96 | 96 | 96 | 90 | 90 | 84 | 84 | ||
| Multidisciplinary Support |
Pearson's correlation | 0,007 | 0,13 | 0,135 | .368** | .292** | .256* | 1 | .422** | .458** | .252* | |
| Sig. (2-tailed) | 0,948 | 0,23 | 0,206 | 0,000 | 0,005 | 0,015 | 0,000 | 0,000 | 0,021 | |||
| N | 89 | 89,00 | 89 | 90 | 90 | 90 | 90 | 90 | 84 | 84 | ||
| Investigations and referrals | Pearson's correlation | 0,032 | .331** | .324** | .395** | .252* | .493** | .422** | 1 | .489** | .288** | |
| Sig. (2-tailed) | 0,769 | 0,00 | 0,002 | 0,000 | 0,017 | 0,000 | 0,000 | 0,000 | 0,008 | |||
| N | 89 | 89,00 | 89 | 90 | 90 | 90 | 90 | 90 | 84 | 84 | ||
| Competence | Pearson's correlation | -0,106 | .368** | .327** | .386** | 0,005 | .321** | .458** | .489** | 1 | .295** | |
| Sig. (2-tailed) | 0,340 | 0,00 | 0,003 | 0,000 | 0,966 | 0,003 | 0,000 | 0,000 | 0,007 | |||
| N | 83 | 83,00 | 83 | 84 | 84 | 84 | 84 | 84 | 84 | 83 | ||
| Physical resources | Pearson's correlation | -.217* | .436** | .483** | .414** | 0,175 | .424** | .252* | .288** | .295** | 1 | |
| Sig. (2-tailed) | 0,048 | 0,00 | 0,000 | 0,000 | 0,111 | 0,000 | 0,021 | 0,008 | 0,007 | |||
| N | 83 | 83,00 | 83 | 84 | 84 | 84 | 84 | 84 | 83 | 84 | ||
| *. The correlation is significant at the 0.05 level (2-tailed). **. The correlation is significant at the level 0.01 level (2-tailed) level. | ||||||||||||
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