The concept of trust in hospitals and the services they provide has become increasingly important in recent years [25]. In the healthcare context, trust is one of the essential and fundamental parts of building a sustainable long-term relationship between patients and healthcare staff [24]. Patient trust can be defined as a set of attitudes or expectations that the clinician will perform their duties in their best interests [12]. Perception of trust between patients and their care providers generally increases their satisfaction and health outcomes [3,7]. There is also evidence that patient trust in their physicians increases the chances of communication about medical problems and subsequent adherence to received medical advice [1]. However, recent studies suggest that trust in public healthcare systems is declining in general and particularly among minority groups [3].

Trust is essential in maternity care where women feel vulnerable due to their health needs creating a power imbalance between them and their carers [32]. Without trust, care providers including midwives and obstetricians are unable to provide appropriate care [14,17]. Albeit there are several studies on patient experience, patient satisfaction, service quality, and how trust relates to these concepts [7,27]; studies on determinants of trust in healthcare settings and maternity services, in particular, are very few. The exceptions include a study by [14] which examined how trust could be rebuilt with women that have had traumatic birth experiences. Trust, together with privacy, community, and culture were further identified as important factors in maternity care for Aboriginal women [23]. A similar study [26] involving women from minority and marginalised groups in British Columbia, Canada, identified mistrust in healthcare providers as having a harmful and negative impact on the maternity care of women from this cohort. These studies provide some initial, but nuanced, understanding of what factors may be related to women's trust in maternity services and possible impacts in the context of women from minority groups.

Past studies have investigated determinants of patient trust in healthcare settings. For instance, Chang et al. [7] showed that perceived quality of service in terms of responsiveness, reliability, and assurance increases patient trust. In the context of maternity services, four groups of factors including patient, provider, health facility, and community factors were found to be determinants of trust based on the interactions between care-users and providers, health facility managers, and policymakers [32]. Trust factors related to care-users include prior birth experiences, perceived risks and harms, childbirth outcomes, and maternal health literacy. Factors associated with providers or caregivers include empathy and respect, responsiveness (including personalised attention), and provider capability.

While respectful care has been related to quality of maternity experience [35], empirical evidence on how it impacts trust is not available. More generally, respectful care should aim to preserve dignity, privacy and confidentiality, ensure freedom from harm and abuse, and provide informed choices and ongoing support during labour and childbirth [6]. The importance of respectful care in maternity services have been studied in different national settings [30,31]. In these studies, respectful care is associated with improved utilisation and quality of maternal care. Results from these studies also show that reducing maternal and early neonatal mortality and morbidity depends on not only increasing facility-based care, but also promoting respectful care. When women feel supported, respected, and safe, and have the opportunity to participate in shared decision-making with their providers, they are more likely to have a positive birth experience [5].

Pain management has also been associated with quality of obstetrics care [36]. Meanwhile, it has been established that doctors showing respect to patients and gaining patient trust during the healthcare process are critical to establishing understanding between patient and doctor, which subsequently affects patient healthcare outcomes [20]. While factors such as informational support [34] and clarity of explanations [2] have been associated with patients’ trust more generally, others factors such as attentiveness [28], pain management, and communication have been associated with enhanced overall satisfaction. These factors are yet to be tested for their influence on women's overall trust in maternity services contexts.

The few available studies on trust in maternity services have understandably largely focused on minority groups in different communities or focus on niche contexts (e.g., trust in healthcare services during Covid-19). There is some empirical evidence on the effect of empathy and respect, responsiveness, personalised attention, and perceived maternity service capability on trust by women in their carers (midwives, nurses, obstetricians, etc.) or maternity services as a whole. This study expands the empirical evidence base on determinants of women's trust in the maternity services professional workforce by investigating the effects of care factors on trust, the relative importance of these factors, and revealing insights on how these factors engender trust.

Specifically, by analysing Ireland's 2020 National Maternity Survey data (the only available data in the series so far) involving 3,205 women from 19 public maternity services, we determined the effect and the strength of 10 major factors on confidence and trust in the professional workforce of these maternity services. These factors include information provision, involvement of women in decision making, involvement their partners or advocate, respect and dignity, attention, personalised attention by carers, communication, responsiveness, pain management, and clarity of explanations. To understand how these factors engender trust, we selected and analysed related free-text comments provided by the women on their care experiences that were collected as part of the survey. The comments provide insights into the conditions associated with good experience and areas for improvement for each of the identified determinants. Finally, we examined if there were differential experiences among socio-demographic groups in particular: age-group, disability, and ethnicity regarding these core trust determinants.