Impact of the Strengthening Teamwork and Respect (STAR) intervention on organisational learning culture and person-centred maternity care in rural South Africa: an uncontrolled before-and-after implementation study.

Background: Respectful maternity care is essential for quality maternal and newborn health services. Interventions to promote respectful care often focus on training, overlooking organisational culture underpinning disrespectful behaviour. This study aimed to evaluate the implementation and effects of the Strengthening Teamwork and Respect (STAR) intervention on organisational learning culture and person-centred maternity care (PCMC). Methods: This implementation research used an uncontrolled before-and-after design with continuous process evaluation in nine district hospitals in KwaZulu-Natal, South Africa. Surveys with postpartum women (baseline n = 893; endline n = 918) and maternity staff (baseline n = 104; endline n = 102) assessed changes in PCMC using the validated PCMC scale and organisational learning culture using the Dimensions of Learning Organisations Questionnaire (DLOQ). Descriptive statistics and Wilcoxon-Rank Sum test explored changes in the DLOQ. PCMC scores were modelled using mixed-effects linear regression including interaction terms with time period (pre-vs post) to examine variation across key predictors. Findings: Five of seven DLOQ dimensions improved, particularly amongst attendees of STAR learning sessions. Mean re-scaled PCMC scores increased from 61.5/100 to 65.7/100 post-intervention (p < 0.0001), with significant improvements in communication and autonomy (53.5/100-59.4/100; p < 0.0001) and supportive care (57.5/100-63.0/100; p < 0.0001). Mixed-effects analysis showed an overall increase of 4.56 percentage points. Women in the lowest socio-economic status group and those with fewer antenatal care visits experienced the largest gains. Interpretation: Modest improvements in organisational learning culture and PCMC were observed following STAR implementation, with larger gains among disadvantaged women. While causal attribution is limited, the findings suggest that participatory approaches targeting organisational culture may support more equitable and respectful maternity care in resource constrained settings. Funding: The Health Systems Research Initiative, supported by the Medical Research Council, the Foreign, Commonwealth and Development Office and Wellcome funded the study in collaboration with the Economic and Social Research Council (grant number MR/V020951/1).