Attitudes and behaviours of maternal health care providers in interactions with clients: a systematic review.
BACKGROUND
High maternal mortality and morbidity persist, in large part due to inadequate access to timely and quality health care. Attitudes and behaviours of maternal health care providers (MHCPs) influence health care seeking and quality of care.


METHODS
Five electronic databases were searched for studies from January 1990 to December 2014. Included studies report on types or impacts of MHCP attitudes and behaviours towards their clients, or the factors influencing these attitudes and behaviours. Attitudes and behaviours mentioned in relation to HIV infection, and studies of health providers outside the formal health system, such as traditional birth attendants, were excluded.


RESULTS
Of 967 titles and 412 abstracts screened, 125 full-text papers were reviewed and 81 included. Around two-thirds used qualitative methods and over half studied public-sector facilities. Most studies were in Africa (n = 55), followed by Asia and the Pacific (n = 17). Fifty-eight studies covered only negative attitudes or behaviours, with a minority describing positive provider behaviours, such as being caring, respectful, sympathetic and helpful. Negative attitudes and behaviours commonly entailed verbal abuse (n = 45), rudeness such as ignoring or ridiculing patients (n = 35), or neglect (n = 32). Studies also documented physical abuse towards women, absenteeism or unavailability of providers, corruption, lack of regard for privacy, poor communication, unwillingness to accommodate traditional practices, and authoritarian or frightening attitudes. These behaviours were influenced by provider workload, patients' attitudes and behaviours, provider beliefs and prejudices, and feelings of superiority among MHCPs. Overall, negative attitudes and behaviours undermined health care seeking and affected patient well-being.


CONCLUSIONS
The review documented a broad range of negative MHCP attitudes and behaviours affecting patient well-being, satisfaction with care and care seeking. Reported negative patient interactions far outweigh positive ones. The nature of the factors which influence health worker attitudes and behaviours suggests that strengthening health systems, and workforce development, including in communication and counselling skills, are important. Greater attention is required to the attitudes and behaviours of MHCPs within efforts to improve maternal health, for the sake of both women and health care providers.
Centre for International Health, Burnet Institute, Melbourne, VIC, Australia. pmannava@gmail.com.
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Mannava
Centre for International Health, Burnet Institute, Melbourne, VIC, Australia. kdurrant@burnet.edu.au.
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Durrant
Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia. jane.fisher@monash.edu.
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Fisher
International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium. matthew.chersich@wits.ac.za.|Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. matthew.chersich@wits.ac.za.
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Chersich
Centre for International Health, Burnet Institute, Melbourne, VIC, Australia. sluchters@burnet.edu.au.|International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium. sluchters@burnet.edu.au.|Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. sluchters@burnet.edu.au.|Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. sluchters@burnet.edu.au.
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Luchters
D001291:Attitude of Health Personnel; D005260:Female; D006801:Humans; D000068097:Maternal Health / Q000592:standards*; D010817:Physician-Patient Relations; D011247:Pregnancy; D011787:Quality of Health Care