Unit culture and respectful care in obstetric care settings: a qualitative concept elicitation study

Unit culture and respectful care in hospital obstetric care settings are associated with patient outcomes and satisfaction. However, the definition and determinants of these concepts from the perspective of staff remain underexplored. We aimed to define unit culture and respectful care, identify their determinants and derive a conceptual framework describing their relationship in obstetric care settings.

A multicenter exploratory qualitative study design was used. Following Institutional Review Board ethical approval, individual interviews were carried out with a volunteer sample of clinical and nonclinical staff working on labor and delivery, antepartum or postpartum units across California to capture comprehensive staff perspectives on obstetric care culture and respectful care. Participants were recruited between March to October 2025, selecting staff representing a range of maternal health providers and birth workers who served diverse regions, communities, and populations. The primary outcome was the definition and conceptual framework of unit staff culture and respectful care in obstetric settings.

Of the 22 participants who agreed to be interviewed, 21 completed interviews were included in the qualitative analysis (Asian 2/21, Black or African American 7/21, White 9/21, not disclosed 3/21). Participants included 9 physicians, 4 nurses, 4 doulas, 1 midwife, and 3 nonclinical staff across 16 healthcare organizations with equal representation of private, public and academic institutions. The mean duration of interview was 50 min. No new themes or subthemes were identified for three consecutive interview transcripts after 18 interviews, indicating thematic saturation had been achieved. Nine themes and 33 subthemes were identified. Unit culture was defined by teamwork, communication, and respectful treatment between staff. Respectful care was characterized by bias-free individualized care, and kindness and equity. Both concepts were influenced by leadership, psychological safety, and strategies to improve culture of respectful care, such as communication and training and staff education, as well as barriers to respectful care, such as resource constraints and implicit biases.

Unit culture and respectful care in obstetric settings were distinct and interrelated concepts. We present a conceptual framework identifying the modifiable determinants that shape both unit culture and respectful care, which can be used to inform improvement strategies.