Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care

**Background:** Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. Previous work has focused on respectful care, but effective interventions remain elusive. This review aimed to establish theoretical principles for interventions to reduce such abuse by looking across health and social care disciplines.

**Methods:** The authors undertook a mixed-methods systematic review of health and social care literature. Databases searched included MEDLINE, SocINDEX, Global Index Medicus, CINAHL, and the Cochrane Library. The initial search was conducted on September 29th, 2020, with an update on March 22nd, 2022; no date or language restrictions were applied. Papers that included theory were analysed narratively. Controlled studies with suitable outcome measures were meta-analysed using inverse variance random effects models, estimating the standardised mean difference (SMD) with 95% confidence intervals. A results-based convergent synthesis was used to integrate findings.

**Key Results:** In the initial search, 17,628 hits were screened, yielding 193 retained papers: 154 provided theoretical explanations and 38 were controlled studies. The update generated 39 studies from 2,695 hits, plus five from reference lists (12 controlled studies). Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint. The pooled outcome showed a statistically significant beneficial effect in reducing restraint (SMD -0.69; 95% CI: -1.15 to -0.24). However, when two outlier studies using mindfulness-based positive behaviour support were excluded, the effect became marginally statistically insignificant (SMD -0.31; 95% CI: -0.79 to 0.17). Sub-group analyses were largely inconclusive. RCTs and CCTs reported a small statistically significant benefit (SMD -0.04; 95% CI: -0.07 to -0.00). Interventions involving both staff and patients had a greater benefit than those focused on staff only (SMD -1.77; 95% CI: -1.82 to -1.73). Most interventions were multi-component. The synthesis of theory papers identified two particular adverse contexts: (1) social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and (2) the belief that mistreatment is necessary to minimise clinical harm. The authors propose that the ethos and expression of mistreatment at each level of the system is moderated by individuals' perceived control, social norms, and perceived benefit.

**Clinical Implications:** Interventions to reduce verbal and physical abuse in maternity care should be locally tailored and informed by theories encompassing all socio-ecological levels, as well as the psychological and emotional responses of individuals working within them. The authors recommend using an integrated socio-ecological-behavioural approach, potentially operationalised through tools like the Behavioural Change Wheel (COM-B model). Attention must be paid to the social normalisation of violence against 'othered' groups and to the paradoxical belief that intrapartum maternal mistreatment optimises safe outcomes. Future studies need consistent outcome measurement to enable comparison and rapid learning.