Respectful maternity care and intersectional identities in low- and middle-income countries: a systematic review.

backgroundDisrespect and abuse (D&A) during facility-based births remains widespread in low- and middle-income countries (LMICs). This disproportionately impacts women from marginalized social strata. Respectful Maternity Care (RMC), as articulated in the 2014 World Health Organization (WHO) statement, constitutes both a fundamental human right and a quality care imperative. However, women's experiences of RMC are not uniform and are influenced by intersecting social identities such as caste, class, ethnicity, age, disability, marital status, language, literacy, and migrant status.

objectivesThis review aimed to (1) quantify and compare the prevalence of disrespect and abuse (D&A) across social subgroups in LMICs; (2) identify social and systemic determinants such as poverty, education, migration status, and provider bias, that influence women's experiences of respectful or disrespectful maternity care; (3) synthesize qualitative insights to understand how intersecting identities shape women's childbirth experiences; and (4) develop a conceptual model explaining how identity factors and health‑system level drivers interact to produce inequities.

methodsWe conducted a systematic review following PRISMA guidelines. We synthesized literature on intersectional experiences of RMC and D&A in LMICs. Searches spanned five databases and key grey literature sources. The data extraction was finalized in April 2025. Eligible studies were published between 2014 (coinciding with the release of the WHO RMC statement) and 2025. Eligible studies included peer-reviewed primary research and high-quality systematic or scoping reviews that provided identity-disaggregated evidence on respectful or disrespectful maternity care in facility-based childbirth settings in LMICs. A thematic narrative synthesis integrated quantitative and qualitative findings. .

resultsSeventeen studies across 15 LMICs were included. Women with intersecting vulnerabilities, especially those who were young, impoverished, unmarried, disabled, lower caste/ethnic minority backgrounds, or migrants, were consistently more susceptible to experience neglect, non-consented care, verbal abuse, or exclusion from decision-making processes. These patterns indicate systemic injustices rather than individual occurrences. Key explanatory mechanisms included social stigma, provider biases about who is "deserving" of care, and communication obstacles. Disability, migration status, socio-economic status, and religion were under-explored in the literature despite being linked to discrimination.

conclusionThis review highlights that intersectional inequities substantially influence women's experiences of respectful maternity care in LMICs. However, causal inference is limited by study heterogeneity and uneven representation of identity factors.