Background: Black women and birthing persons in the US suffer the gravest maternal outcomes, including severe maternal morbidity, and they experience the least respectful treatment during maternity care. Respectful and responsive treatment during maternity is an ethical imperative critical to high-quality care. Every possible factor that might contribute to the adverse outcomes of Black women in maternity care must be considered, including the potential relationship between respectful maternity care and clinical and psychological outcomes.

Purpose: This research aims to examine the ethical perspectives of respectful maternity care (RMC) by exploring how the four ethical principles—autonomy, beneficence, non-maleficence, and justice—relate to RMC, along with other ethical frameworks for improving maternity care quality. The study also estimates the occurrence of disrespectful treatment in maternity care and explores potential associations between disrespectful treatment and indicators of severe maternal morbidity (SMM), postpartum depression, and thoughts of self-harm.

Methods: To address the first study's aim, a literature review was conducted to provide an overview of ethical principles supporting the implementation of respectful maternity care. Cross-sectional data were collected from a convenience sample comprising English-speaking Black women who had given birth in a hospital within the Baltimore/Washington, DC metropolitan area within the past five years. Descriptive statistics were used to analyze demographic variables, reported levels of respect, SMM indicators, depression, and thoughts of self-harm. Logistic regression analyses examined the association between RMC and indicators of SMM, postpartum depression, and thoughts of self-harm. Results: Birthing persons in our sample encountered lower respect than the national average, with sixty percent reporting less than highly respectful treatment. Forty percent reported an indicator of SMM. Those who reported low (OR = 2.86, 95% CI [1.47 - 5.55] or moderate levels OR = 2.56, 95% CI [1.43 - 4.57] of respect were more likely to report experiencing an indicator of SMM compared to those who were treated with high levels of respect. Approximately thirty percent of the sample had symptoms of postpartum depression, and almost sixteen percent reported having thoughts of self-harm. Compared to those treated with high levels of respect, those treated with low levels of respect were more likely to report having postpartum depression (OR = 11.13, 95% CI [4.68 – 26.47] and thoughts of self-harm (OR = 8.05, 95% CI [2.8 – 22.87].

Conclusion: A review of the literature revealed that the standard ethical principles of healthcare are foundational to how respectful maternity care is conceptualized and practiced. Additional frameworks emerged - care ethics and human rights-based ethics, that provide detailed guidance on connecting respectfully in the care process. Our findings suggest that ethically based respectful maternity care can improve maternity outcomes for Black birthing persons. Both clinical and psychological morbidity are associated with how individuals encounter maternity care. Less respectful treatment is significantly associated with the adverse outcomes of severe maternal morbidity, postpartum depression, and thoughts of self-harm.