Accountability for respectful maternity care

Accountability for maternal and newborn health: Why measuring and monitoring broader social, political, and health system determinants matters

This article offers four key lessons learned from a set of seven studies undertaken as part of the collection entitled, "Improving Maternal Health Measurement to Support Efforts toward Ending Preventable Maternal Mortality". These papers were aimed at validating ten of the Ending Preventable Maternal Mortality initiative indicators that capture information on distal causes of maternal mortality. These ten indicators were selected through an inclusive consultative process, and the research designs adhere to global recommendations on conducting indicator validation studies. The findings of these papers are timely and relevant given growing recognition of the role of macro-level social, political, and economic factors in maternal and newborn survival. The four key lessons include: 1) Strengthen efforts to capture maternal and newborn health policies to enable global progress assessments while reducing multiple requests to countries for similar data; 2) Monitor indicator "bundles" to understand degree of policy implementation, inconsistencies between laws and practices, and responsiveness of policies to individual and community needs; 3) Promote regular monitoring of a holistic set of human resource metrics to understand how to effectively strengthen the maternal and newborn health workforce; and 4) Develop and disseminate clear guidance for countries on how to assess health system as well as broader social and political determinants of maternal and newborn health. These lessons are consistent with the Kirkland principles of focus, relevance, innovation, equity, global leadership, and country ownership. They stress the value of indicator sets to understand complex phenomenon related to maternal and newborn health, including small groupings of complementary indicators for measuring policy implementation and health workforce issues. They also stress the fundamental ethos that maternal and newborn health indicators should only be tracked if they can drive actions at global, regional, national, or sub-national levels that improve lives.

"Normal in all the rush": A phenomenological study analyzing midwifery students' views on obstetric violence

INTRODUCTION

In recent years, obstetric violence, which undermines women's dignity and autonomy, has received increased attention worldwide. Considering the importance of midwives in combating violence in the obstetric field and the significance of the discussed issue, the following question arises: How do future midwives view obstetric violence?

OBJECTIVE

This study aimed to investigate midwifery students' thoughts about obstetric violence.

DESIGN AND METHOD

This study was conducted using a phenomenological qualitative research design. This study, which adopted a descriptive approach and used typical case sampling, was conducted in the midwifery department of the Kutahya Health Sciences University. Sixteen midwifery students studying fourth-year in the 2018-2019 academic year, who had participated in childbirth during their studies, and who agreed to participate in the study were included. All students had the experience of repeated monitoring and presence in labor. They had witnessed births in different institutions. Focus group interviews were conducted using an unstructured interview guide to obtain data for the study. Data were collected through four focus group interviews with groups of four students in the classroom environment. The data were evaluated separately by two researchers using the content analysis method in MAXQDA Analytics Pro 2020. The Consolidated Criteria for Reporting Qualitative Studies guidelines were used as a guide in reporting.

RESULTS

As a result of the analysis, four main themes emerged: defining violence, causes of violence, effects of witnessing violence, and whether can violence be prevented?

CONCLUSIONS

Midwifery students have an awareness of all visible forms of obstetric violence. However, they were less aware of the invisible structural and policy drivers of obstetric violence. It is invaluable to raise awareness of obstetric violence among midwifery students, who will be the most important defenders of women in childbirth. Studies focused on education and policy will contribute to women receiving quality care at birth.

Understanding the Mechanisms of Change in the Supportive and Respectful Maternity Care Intervention in Sindh, Pakistan: Provider Perspectives

INTRODUCTION

We conducted this qualitative investigation to explore the mechanisms of change in providing respectful care resulting from the supportive and respectful maternity care intervention (S-RMC) in Sindh, Pakistan.

METHODS

We applied the principles of realist evaluation methodology with a descriptive explanatory research design. We conducted in-depth interviews with 36 maternity care providers at secondary-level public health facilities where S-RMC was implemented for 6 months. The S-RMC broad components included capacity-building of maternity teams and systemic changes for improvements in governance and accountability within public health facilities. Data were analyzed using a deductive content analysis approach.

RESULTS

We identified mechanisms of change, categorized by the S-RMC components: (1) S-RMC training: insight into women's feelings and rights, realization of the value that nonclinical staff can play, understanding of team coordination, orientation in psychosocial components of maternity care; (2) assessment of women's psychosocial vulnerabilities: identification of women's differential needs beyond routine care to provide woman-centered care; (3) psychosocial support: effective engagement with women and within maternity teams and the customization of woman- and companion-focused care; (4) care coordination: improved coordination among clinical and nonclinical staff to provide personalized care and psychosocial support and proper handover to ensure continuity of care; (5) assessment of quality of care: identification of service gaps from women's feedback; and (6) performance review and accountability: monthly performance review meetings to establish team member communication, systematic awareness of the maternity team's performance and challenges, and implementation of collective corrective actions.

CONCLUSION

Our findings pointed to S-RMC working along multiple pathways-and concertedly with various health system components-to enable positive processes and behavioral change in maternity teams.

Cross-cultural adaptation and psychometric properties of the Chinese version of the Person-Centered Maternity Care Scale

BACKGROUND

Increasing evidence show that women across the world face unacceptable mistreatment during childbirth. Person-centered maternity care is fundamental and essential to quality of healthcare services. The aim of this study was to translate and determine the psychometric properties of the Person-Centered Maternity Care (PCMC) Scale among Chinese postpartum women.

METHODS

A cross-sectional study was conducted among 1235 post-partum women in China. The cross-cultural adaptation process followed the Beaton intercultural debugging guidelines. A total of 1235 women were included to establish the psychometric properties of the PCMC. A demographic characteristics form and the PCMC were used for data collection. The psychometric properties of the PCMC were evaluated by examining item analysis, exploratory factor analysis, known-groups discriminant validity, and internal consistency.

RESULTS

The number of extracted common factors was limited to three (dignity & respect, communication & autonomy, supportive care), explaining a total variance of 40.8%. Regarding internal consistency, the Cronbach's alpha coefficient and split-half reliability of the full PCMC score were 0.989 and 0.852, respectively.

CONCLUSIONS

The Chinese version of the PCMC is a reliable and valid tool to assess person-centered care during childbirth in China.

Association of workload and practice of respectful maternity care among the healthcare providers, before and during the early phase of COVID-19 pandemic in South Western Nepal: a cross-sectional study

INTRODUCTION

Respectful maternity care is an approach that involves respecting women's belief, choices, emotions, and dignity during the childbirth process. As the workload among maternity care workforce affects intrapartum quality care, respectful maternity care might have also been affected, particularly during the pandemic. Thus, this study was conducted to examine the association between workload among healthcare providers and their practice of respectful maternity care, before and during the early phase of pandemic.

METHODS

A cross-sectional study was conducted in South Western Nepal. A total of 267 healthcare providers from 78 birthing centers were included. Data collection was done through telephone interviews. The exposure variable was workload among the healthcare providers, and the outcome variable was respectful maternity care practice before and during the COVID-19 pandemic. Multilevel mixed-effect linear regression was used to examine the association.

RESULTS

The median client-provider ratio before and during the pandemic was 21.7 and 13.0, respectively. The mean score of respectful maternity care practice was 44.5 (SD 3.8) before the pandemic, which was decreased to 43.6 (SD 4.5) during the pandemic. Client-provider ratio was negatively associated with respectful maternity care practice for both times; before (Coef. -5.16; 95% CI -8.41 to -1.91) and during (Coef. -7.47; 95% CI -12.72 to -2.23) the pandemic.

CONCLUSIONS

While a higher client-provider was associated with a lower respectful maternity care practice score both before and during the COVID-19 pandemic, the coefficient was larger during the pandemic. Therefore, workload among the healthcare providers should be considered before the implementation of respectful maternity care, and more attention should be given during the pandemic.

“We know it is not good, but we are constrained”: A study on quality of emergency obstetric and newborn care in Northern Ghana

Objective

To explore the quality of emergency obstetric and newborn care provided to newly delivered women in rural Ghana.

Methods

A multiple case study design, involving in-depth face to face interviews, was deployed to draw evidence from essential health providers, clients and caretakers. Data were further derived from non-participant observation by means of an observation guide and analysis of physical artifacts using the room-by-room walk-through tool. Data analysis followed Yin's five phase process to case study analysis.

Results

Quality of care was compromised by non-adherence to standard practices, inadequate monitoring, crude treatment procedures, lack of basic care needs and poor health providers' relational behaviours. Limited supplies of drugs, equipment and essential care providers further weakened the provision of quality emergency obstetric and newborn care.

Conclusion

Inadequate supply of essential logistics and skill gaps on the part of health providers in some maternal and newborn care components adversely produced poor maternal and neonatal outcomes in rural Ghana. Elements of disrespectful care for women suggest violations of their rights in the maternal and newborn care encounter.

The design, delivery and evaluation of 'Human Perspectives VR': An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD

BACKGROUND

A traumatic childbirth experience affects ~30% of women each year, with negative impacts on maternal, infant, and family wellbeing. Women classified as vulnerable or marginalised are those more likely to experience a psychologically traumatising birth. A key contributory factor for a traumatic childbirth experience is women's relationships with maternity care providers.

AIMS

To develop, design and evaluate an immersive educational programme for maternity care providers to raise awareness of traumatic childbirth experiences amongst vulnerable groups, and ultimately to improve women's experiences of childbirth.

METHODS

A critical pedagogical approach that utilised virtual reality (VR) underpinned the design and development of the educational programme. This involved: a) collecting vulnerable/disadvantaged women's experiences of birth via interviews; b) analysing data collected to identify key hotspots for traumatic experiences within interpersonal patient-provider relationships to develop a script; c) filming the script with professional actors creating a first person perspective via VR technology; d) using existing literature to inform the theoretical and reflective aspects of the programme; e) conducting an evaluation of the education programme using pre-and post-evaluation questionnaires and a follow-up focus group.

FINDINGS

Human Perspective VR was very well received. Participants considered the content to have enhanced their reflective practice and increased their knowledge base regarding contributory factors associated with a traumatic childbirth experience. A need for further work to implement learning into practice was highlighted.

CONCLUSION

While further research is needed to evaluate the impact of the programme, Human Perspective VR programme offers an innovative approach to reflective education and to enhance participants' care practices.

Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Background

Respectful maternity care encompasses the right to continuity of care and dignified support for women during the reproductive period, enabling informed choice. However, the evidence is limited in the context of South Asia region where maternal, perinatal and newborn mortality is still a critical challenge to health systems. Evidence is required to better understand the context of respectful maternity care to inform directions for appropriate policy and practice.

Objective

The objective of this scoping review was to explore facilitators and barriers of respectful maternity care practice in South Asia.

Design

CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases were used to identify related studies. Data were systematically synthesized and analysed thematically.

Findings

There was considerable heterogeneity in the 61 included studies from seven South Asian countries, with most of the research conducted in Nepal and India. While the experience of abuse and neglect was common, 10 critical themes emerged related to neglected choices and compromised quality of care (particularly where there were health inequities) in the context of institutional care experiences; and the imperative for improved investment in training and significant policy and legislative change to enforce equitable and respectful maternity care practice.

Conclusions and Implications for Practice

Evidence about respectful maternity care in South Asia indicates that women accessing professional and facility-based services experienced high levels of disrespect, abuse and maltreatment. Women from vulnerable, socially disadvantaged and economically poor backgrounds were more likely to experience higher level abuse and receive poor quality of care. There is an urgent need for a well-resourced, sustained commitment to mandate and support the provision of respectful and equitable maternity care practice in South Asia.

Exposing Obstetric Violence in the Eastern Mediterranean Region: A Review of Women's Narratives of Disrespect and Abuse in Childbirth

Background

Obstetric violence (OV) threatens the provision of dignified, rights-based, high-quality, and respectful maternal care (RMC). The dearth of evidence on OV in the Eastern Mediterranean Region poses a knowledge gap requiring research to improve rights-based and respectful health practice and policy. While efforts to improve the quality of maternal health have long-existed, women's experiences of childbirth and perceptions of dignity and respect are not adequately or systematically recorded, especially in the said region.

Aim

This study centered on the experiences of women's mistreatment in childbirth to provide an overview of OV and offer recommendations to improve RMC.

Methods

A scoping review was conducted, and a total of 38 articles met the inclusion criteria and were analyzed using Bowser and Hill's framework of the seven typologies of Disrespect and Abuse (D&A) in childbirth. D&A in childbirth (or violations to RMC) is a manifestation of OV and served as a proxy to analyze its prevalence in the EMR.

Findings and Discussion

This study indicated that across the EMR, women experienced every type of D&A in childbirth. This happens regardless of health systems' strength or country's income, with 6 out of 7 types of D&A found in almost two-thirds of included countries. In the EMR, the most common types of D&A in childbirth are physical abuse (especially overused routine interventions) and non-dignified care (embedded in patriarchal socio-cultural norms). The intersections of these abuses enable the objectification of women's bodies and overuse of unconsented routine interventions in a hierarchical and patriarchal system that regards the power and autonomy of doctors above birthing women. If unchecked, the implications include acceptance, continuation, and underreporting of D&A in childbirth, as well as passivity toward human-rights violations, which all further cause the continuing the cycle of OV.

Conclusion

In order to eliminate OV, a paradigm shift is required involving infrastructure changes, education, empowerment, advocacy, a women-centered and gender-sensitive approach to health system strengthening, and policy development. Recommendations are given at individual, community, health systems, and policy levels to ensure that every woman achieves her right to health and birth in a dignified, respectful, and empowered manner.

To call or not to call: exploring the validity of telephone interviews to derive maternal self-reports of experiences with facility childbirth care in northern Nigeria

Background

To institutionalise respectful maternity care, frequent data on the experience of childbirth care is needed by health facility staff and managers. Telephone interviews have been proposed as a low-cost alternative to derive timely and actionable maternal self-reports of experience of care. However, evidence on the validity of telephone interviews for this purpose is limited.

Methods

Eight indicators of positive maternity care experience and 18 indicators of negative maternity care experience were investigated. We compared the responses from exit interviews with women about their childbirth care experience (reference standard) to follow-up telephone interviews with the same women 14 months after childbirth. We calculated individual-level validity metrics including, agreement, sensitivity, specificity, area under the receiver operating characteristic curve (AUC). We compared the characteristics of women included in the telephone follow-up interviews to those from the exit interviews.

Results

Demographic characteristics were similar between the original exit interview group (n=388) and those subsequently reached for telephone interview (n=294). Seven of the eight positive maternity care experience indicators had reported prevalence higher than 50% at both exit and telephone interviews. For these indicators, agreement between the exit and the telephone interviews ranged between 50% and 92%; seven positive indicators met the criteria for validation analysis, but all had an AUC below 0.6. Reported prevalence for 15 of the 18 negative maternity care experience indicators was lower than 5% at exit and telephone interviews. For these 15 indicators, agreement between exit and telephone interview was high at over 80%. Just three negative indicators met the criteria for validation analysis, and all had an AUC below 0.6.

Conclusions

The telephone interviews conducted 14 months after childbirth did not yield results that were consistent with exit interviews conducted at the time of facility discharge. Women’s reports of experience of childbirth care may be influenced by the location of reporting or changes in the recall of experiences of care over time.

Magnitude and associated factors of disrespect and abusive care among laboring mothers at public health facilities in Borena District, South Wollo, Ethiopia

BACKGROUND

Recent studies have indicated that disrespectful/abusive/coercive service by skilled care providers in health facilities that results in actual or perceived poor quality of care is directly and indirectly associated with adverse maternal and newborn outcomes. According to the 2016 Ethiopian Demography and Health Survey, only 26% of births were attended by qualified clinicians, with a maternal mortality rate of 412 per 100,000 live-births. Using seven categories developed by Bowser and Hill (2010), this study looked at disrespect and abuse experienced by women in labor and delivery rooms in health facilities of Borena Ddistrict, South Wollo, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted among 374 immediate postpartum women in Borena District from January 12 to March 12, 2020. Systematic sampling was used to access respondents to participate in a structured, pre-tested face-to-face exit interview. Data were entered into EpiData version 4.6 and exported to SPSS version 25 for analysis. Finally, bivariable and multivariable logistic regression analysis were performed to declare statistically significant factors related to maternal disrespect and abusive care in Borena District at a p-value of < 0.05 and at 95% CI.

RESULT

Almost four out of five (79.4%) women experienced at least one type of disrespect and abuse during facility-based childbirth. The most frequently reported type of disrespect and abuse was non-consented care 63.7%. Wealth index [AOR = 3.27; 95% CI: (1.47, 7.25)], type of health facility [AOR = 1.96; 95% CI: (1.01, 3.78)], presence of companion(s) [AOR = 0.05; 95% CI: (0.02, 0.12)], and presence of complications [AOR = 2.65; 95% CI: (1.17, 5.99)] were factors found to be significantly related to women experiencing disrespect and abuse.

CONCLUSION

The results showed that wealth index, type of health facility, presence of companion(s), and birth complications were found to be significant factors. Therefore, health personnel need to develop interventions that integrate provider's behavior on companionship and prevention of complications across facilities to reduce the impact of disrespectful and abusive care for laboring women.

Understanding Women's Choices: How Women's Perceptions of Quality of Care Influences Place of Delivery in a Rural Sub-County in Kenya. A Qualitative Study

BACKGROUND

Maternal mortality is still unacceptably high in Kenya. The Kenyan Government introduced a free maternity service to overcome financial barriers to access. This policy led to a substantial increase in women's delivery options. This increase in coverage might have led to a reduction in quality of care. This study explores women's perceptions of quality of delivery services in the context of the free policy and how the perceptions lead to the choice of a place for delivery.

METHODS

Our study site was Naivasha sub-County in Kenya, a rural context, whose geography encompasses pastoralists, rural agrarian, and high population density informal settlements near flower farms. Women from this area are from the lowest wealth quintile in Kenya. We conducted a qualitative study to explore the women's perceptions of quality of care based on their experiences during maternity care. The participants were women of reproductive age (18-49 years) attending antenatal care clinics at six health facilities in the sub-county. Six focus group discussions with 55 respondents were used. For inclusion, the women needed to have delivered a baby within the six months preceding the study. Interviews were recorded with consent, translated and transcribed. The interviews were analyzed using a thematic content approach.

RESULTS

Four broad themes that determined the choice of health facility for delivery were identified: women's perceptions of clinical quality of care; the cost of delivery; distance to the health facility and management of primary health facilities. An unexpected theme was the presence of home deliveries amongst pastoralist women. These findings suggest that in this setting both process and structural dimensions of quality of care and financial and physical accessibility influence women's choices for place of delivery.

CONCLUSION

This study expands our understanding of how women make choices regarding place of delivery. Understanding women's perceptions can provide useful insights to policy makers and facility managers on providing high quality patient centered maternity care necessary to sustain the increased utilization of maternity services at health facilities under the free maternity policy and further reductions in maternal mortality.

Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee-exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC.

Assessment of the attitude towards childbirth in health sciences students - development and validation of the questionnaire Cave-St

The purpose of this study is to report on the validation process of a questionnaire that explores health science students’ attitudes towards women’s childbirth experiences. This questionnaire can help inform education programs to enhance the quality of woman-professional interactions, and to improve women’s experiences of childbirth. A standardized procedure for the development and validation of the questionnaire included: item development and psychometric pre-validation, Cronbach’s Alpha coefficient calculation, test–retest and item-total correlation for the reliability analysis. Content validity was undertaken by Delphi method with sixteen panelists over two rounds. We determined the factor structure and refined and validated the questionnaire according to the responses of a cohort of 560 students using principal components factor analysis with varimax rotation. Confirmatory factor analysis was undertaken. A 52-items questionnaire CAVE-st: (acronym for cuestionario de actitudes sobre vivencias y experiencias en el parto) was developed and validated. The results of the factor analysis finally revealed four latent dimensions. The questionnaire CAVE-st is a valid and reliable tool to assess health science students’ attitude towards women’s childbirth experiences. Further work to translate and adapt the instrument in other cultures and languages will be undertaken.

Exploring women's childbirth experiences and perceptions of delivery care in peri-urban settings in Nairobi, Kenya

BACKGROUND

Kenya continues to have a high maternal mortality rate that is showing slow progress in improving. Peri-urban settings in Kenya have been reported to exhibit higher rates of maternal death during labor and childbirth as compared to the general Kenyan population. Although research indicates that women in Kenya have increased access to facility-based birth in recent years, a small percentage still give birth outside of the health facility due to access challenges and poor maternal health service quality. Most studies assessing facility-based births have focused on the sociodemographic determinants of birthing location. Few studies have assessed women's user experiences and perceptions of quality of care during childbirth. Understanding women's experiences can provide different stakeholders with strategies to structure the provision of maternity care to be person-centered and to contribute to improvements in women's satisfaction with health services and maternal health outcomes.

METHODS

A qualitative study was conducted, whereby 70 women from the peri-urban area of Embakasi in the East side of Nairobi City in Kenya were interviewed. Respondents were aged 18 to 49 years and had delivered in a health facility in the preceding six weeks. We conducted in-depth interviews with women who gave birth at both public and private health facilities. The interviews were recorded, transcribed, and translated for analysis. Braune and Clarke's guidelines for thematic analysis were used to generate themes from the interview data.

RESULTS

Four main themes emerged from the analysis. Women had positive experiences when care was person-centered-i.e. responsive, dignified, supportive, and with respectful communication. They had negative experiences when they were mistreated, which was manifested as non-responsive care (including poor reception and long wait times), non-dignified care (including verbal and physical abuse lack of privacy and confidentiality), lack of respectful communication, and lack of supportive care (including being denied companions, neglect and abandonment, and poor facility environment).

CONCLUSION

To sustain the gains in increased access to facility-based births, there is a need to improve person-centered care to ensure women have positive facility-based childbirth experiences.

Person-centered antenatal care and associated factors in Rwanda: a secondary analysis of program data

BACKGROUND

Research suggests that women's experience of antenatal care is an important component of high-quality antenatal care. Person-centered antenatal care (PCANC) reflects care that is both respectful of, and responsive to, the preferences, needs, and values of pregnant women. Little is known in Rwanda about either the extent to which PCANC is practiced or the factors that might determine its use. This is the first study to quantitatively examine the extent of and the factors associated with PCANC in Rwanda.

METHODS

We used quantitative data from a randomized control trial in Rwanda. A total of 2150 surveys were collected and analyzed from 36 health centers across five districts. We excluded women who were less than 16 years old, were referred to higher levels of antenatal care or had incomplete survey responses. Both bivariate and multivariate logistic regression analyses were used to test the hypothesis that certain participant characteristics would predict high PCANC.

RESULTS

PCANC level was found to be sub-optimal with one third of women leaving antenatal care (ANC) with questions or confused and one fourth feeling disrespected. In bivariate analysis, social support, greater parity, being in the traditional care (control group), and being from Burera district significantly predict high PCANC. Additionally, in the multivariate analysis, being in the traditional care group and the district in which women received care were significantly associated with PCANC.

CONCLUSIONS

This quantitative analysis indicates sub-optimal levels of PCANC amongst our study population in Rwanda. We find lower levels of PCANC to be regional and defined by the patient characteristics parity and social support. Given the benefits of PCANC, improvements in PCANC through provider training in Rwanda might promote an institutional culture shift towards a more person-centered model of care.

Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal

BACKGROUND

Respectful maternal and newborn care (RMNC) is an important component of high-quality care but progress is impeded by critical measurement gaps for women and newborns. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study was an observational study with mixed methods assessing measurement validity for coverage and quality of maternal and newborn indicators. This paper reports results regarding the measurement of respectful care for women and newborns.

METHODS

At one EN-BIRTH study site in Pokhara, Nepal, we included additional questions during exit-survey interviews with women about their experiences (July 2017-July 2018). The questionnaire was based on seven mistreatment typologies: Physical; Sexual; or Verbal abuse; Stigma/discrimination; Failure to meet professional standards of care; Poor rapport between women and providers; and Health care denied due to inability to pay. We calculated associations between these typologies and potential determinants of health - ethnicity, age, sex, mode of birth - as possible predictors for reporting poor care.

RESULTS

Among 4296 women interviewed, none reported physical, sexual, or verbal abuse. 15.7% of women were dissatisfied with privacy, and 13.0% of women reported their birth experience did not meet their religious and cultural needs. In descriptive analysis, adjusted odds ratios and multivariate analysis showed primiparous women were less likely to report respectful care (β = 0.23, p-value < 0.0001). Women from Madeshi (a disadvantaged ethnic group) were more likely to report poor care (β = - 0.34; p-value 0.037) than women identifying as Chettri/Brahmin. Women who had caesarean section were less likely to report poor care during childbirth (β = - 0.42; p-value < 0.0001) than women with a vaginal birth. However, babies born by caesarean had a 98% decrease in the odds (aOR = 0.02, 95% CI, 0.01-0.05) of receiving skin-to-skin contact than those with vaginal births.

CONCLUSIONS

Measurement of respectful care at exit interview after hospital birth is challenging, and women generally reported 100% respectful care for themselves and their baby. Specific questions, with stratification by mode of birth, women's age and ethnicity, are important to identify those mistreated during care and to prioritise action. More research is needed to develop evidence-based measures to track experience of care, including zero separation for the mother-newborn pair, and to improve monitoring.

Why do some health care providers disrespect and abuse women during childbirth in India?

BACKGROUND

Disrespect and abuse during childbirth can result in fear of childbirth. Consequently, women may be discouraged to seek care, increasing the likelihood for women to choose elective cesarean section in order to avoid humiliation, postnatal depression and even maternal mortality. This study investigates the causes underlying mistreatment of women during childbirth by health care providers in India, where evidence of disrespect and abuse has been reported.

METHODS

Qualitative research was undertaken involving 34 in-depth interviews with midwifery and nursing leaders from India who represent administration, advocacy, education, regulation, research and service provision at state and national levels. Data are analysed thematically with NVivo12. The analysis added value by bringing an international perspective from interviews with midwifery leaders from Switzerland and the United Kingdom.

FINDINGS

The factors leading to disrespect and abuse of women relate to characteristics of both women and their midwives. Relevant woman-related attributes include her age, gender, physical appearance and education, extending to the social environment including her social status, family support, culture of abuse, myths around childbirth and sex-based discrimination. Midwife-related factors include gender, workload, medical hierarchy, bullying and powerlessness.

DISCUSSION

The intersectionality of factors associated with mistreatment during childbirth operate at individual, infrastructural, social and policy levels for both the women and nurse-midwives, and these factors could exacerbate existing gender-based inequalities. Maternal health policies should address the complex interplay of these factors to ensure a positive birthing experience for women in India.

CONCLUSION

Maternal health interventions could improve by integrating women-centred protocols and monitoring measures to ensure respectful and dignified care during childbirth.

Eliciting women's preferences for place of child birth at a peri-urban setting in Nairobi, Kenya: A discrete choice experiment

Objective

Maternal and newborn mortality rates are high in peri-urban areas in cities in Kenya, yet little is known about what drives women’s decisions on where to deliver. This study aimed at understanding women’s preferences on place of childbirth and how sociodemographic factors shape these preferences.

Methods

This study used a Discrete Choice Experiment (DCE) to quantify the relative importance of attributes on women’s choice of place of childbirth within a peri-urban setting in Nairobi, Kenya. Participants were women aged 18–49 years, who had delivered at six health facilities. The DCE consisted of six attributes: cleanliness, availability of medical equipment and drug supplies, attitude of healthcare worker, cost of delivery services, the quality of clinical services, distance and an opt-out alternative. Each woman received eight questions. A conditional logit model established the relative strength of preferences. A mixed logit model was used to assess how women’s preferences for selected attributes changed based on their sociodemographic characteristics.

Results

411 women participated in the Discrete Choice Experiment, a response rate of 97.6% and completed 20,080 choice tasks. Health facility cleanliness was found to have the strongest association with choice of health facility (β = 1.488 p<0.001) followed respectively by medical equipment and supplies availability (β = 1.435 p<0.001). The opt-out alternative (β = 1.424 p<0.001) came third. The attitude of the health care workers (β = 1.347, p<0.001), quality of clinical services (β = 0.385, p<0.001), distance (β = 0.339, p<0.001) and cost (β = 0.0002 p<0.001) were ranked 4^th to 7^th respectively. Women who were younger and were the main income earners having a stronger preference for clean health facilities. Older married women had stronger preference for availability of medical equipment and kind healthcare workers.

Conclusions

Women preferred both technical and process indicators of quality of care. DCE’s can lead to the development of person-centered strategies that take into account the preferences of women to improve maternal and newborn health outcomes.

Understanding what women want: eliciting preference for delivery health facility in a rural subcounty in Kenya, a discrete choice experiment

OBJECTIVE

To identify what women want in a delivery health facility and how they rank the attributes that influence the choice of a place of delivery.

DESIGN

A discrete choice experiment (DCE) was conducted to elicit rural women's preferences for choice of delivery health facility. Data were analysed using a conditional logit model to evaluate the relative importance of the selected attributes. A mixed multinomial model evaluated how interactions with sociodemographic variables influence the choice of the selected attributes.

SETTING

Six health facilities in a rural subcounty.

PARTICIPANTS

Women aged 18-49 years who had delivered within 6 weeks.

PRIMARY OUTCOME

The DCE required women to select from hypothetical health facility A or B or opt-out alternative.

RESULTS

A total of 474 participants were sampled, 466 participants completed the survey (response rate 98%). The attribute with the strongest association with health facility preference was having a kind and supportive healthcare worker (β=1.184, p<0.001), second availability of medical equipment and drug supplies (β=1.073, p<0.001) and third quality of clinical services (β=0.826, p<0.001). Distance, availability of referral services and costs were ranked fourth, fifth and sixth, respectively (β=0.457, p<0.001; β=0.266, p<0.001; and β=0.000018, p<0.001). The opt-out alternative ranked last suggesting a disutility for home delivery (β=-0.849, p<0.001).

CONCLUSION

The most highly valued attribute was a process indicator of quality of care followed by technical indicators. Policymakers need to consider women's preferences to inform strategies that are person centred and lead to improvements in quality of care during delivery.

Development and psychometric properties of Midwives' Knowledge and Practice Scale on Respectful Maternity Care (MKP-RMC)

Objective

To develop a scale for evaluating knowledge and practice of midwives on Respectful Maternity Care (RMC).

Methods

An exploratory sequential mixed method study was conducted from January 2018 to July 2019 in two non-teaching public hospitals in Tehran, Iran. In the first part of the study, a literature review and qualitative study were carried out in order to develop the preliminary item pool. Then face, content and construct validity and reliability (internal consistency and test-retest) were assessed.

Results

The MKP-RMC scale has 23-item in knowledge and 23-item in practice section that loaded in three factors: Giving emotional support, providing safe care and preventing mistreatment. Exploratory factor analysis accounted for 43.47% and 58.62% of observed variance in knowledge and practice sections, respectively. The internal consistency and internal correlation coefficient of both section of MKP-RMC indicated acceptable reliability.

Conclusion

The MKP-RMC is a valid and reliable tool for measuring midwives' knowledge and practice of respectful care during labor and childbirth. The MKP-RMC could be used in maternity services to evaluate and improve quality of childbirth care through development of educational interventions for effective behavioral change. Confirmation of validity and reliability of translated version of the scale in other maternity care providers and different contexts is recommended.

'We just look at the well-being of the baby and not the money required': a qualitative study exploring experiences of quality of maternity care among women in Nairobi's informal settlements in Kenya

OBJECTIVE

To examine how women living in an informal settlement in Nairobi perceive the quality of maternity care and how it influences their choice of a delivery health facility.

DESIGN

Qualitative study.

SETTINGS

Dandora, an informal settlement, Nairobi City in Kenya.

PARTICIPANTS

Six focus group discussions with 40 purposively selected women aged 18-49 years at six health facilities.

RESULTS

Four broad themes were identified: (1) perceived quality of the delivery services, (2) financial access to delivery service, (3) physical amenities at the health facility, and (4) the 2017 health workers' strike.The four facilitators that influenced women to choose a private health facility were: (1) interpersonal treatment at health facilities, (2) perceived quality of clinical services, (3) financial access to health services at the facility, and (4) the physical amenities at the health facility. The three barriers to choosing a private facility were: (1) poor quality clinical services at low-cost health facilities, (2) shortage of specialist doctors, and (3) referral to public health facilities during emergencies.The facilitators that influenced women to choose a public facility were: (1) physical amenities for dealing with obstetric emergencies and (2) early referral to public maternity during antenatal care services. Barriers to choosing a public facility were: (1) perception of poor quality clinical services, (2) concerns over security for newborns at tertiary health facilities, (3) fear of mistreatment during delivery, (4) use of unsupervised trainee doctors for deliveries, (5) poor quality of physical amenities, and (6) inadequate staffing.

CONCLUSION

The study provides insights into decision-making processes for women when choosing a delivery facility by identifying critical attributes that they value and how perceptions of quality influence their choices.

Women's suggestions on how to improve the quality of maternal and newborn hospital care: a qualitative study in Italy using the WHO standards as framework for the analysis

BACKGROUND

A recent systematic review identified very few studies on women's views on how to improve the quality of maternal and newborn care (QMNC). This study aimed at exploring the suggestions provided by women, after hospital delivery in Italy, on how to improve the QMNC.

METHODS

A questionnaire, containing open questions to capture suggestions on how to improve QMNC, was used to collect suggestions of mothers who gave birth a tertiary care referral hospital in Northeast Italy, between December 2016 and September 2018. Two authors independently used thematic analysis to analyse women's comments, using the WHO Standards for improving the QMNC as framework for the analysis.

RESULTS

Overall 392 mothers provided a total of 966 comments on how to improve the QMNC. Overall 45 (11.5%) women made suggestions pertinent to "provision of care", 222 (56.6%) to the "experience of care", 217 (55.4%) to "physical or to human resources". The top five suggestions were: 1) increase presence of a companion during the whole hospitalization (28.3% of women); 2) improve bathrooms and showers (18.4%); 3) improve effective communication from staff (14.0%); 4) improve staff professionalism, empathy, and kindness (13.5%); 5) increase support and information on how to provide care to the newborn (11.2%). Overall, 158 (16.4%) suggestions could not be classified in any WHO Standards, and among these most (72.1%) were related to physical structures, such as: decrease the number of patients per room; create areas for visitors; avoid case mixing in the same room; reduce rooming-in/better support the mother. Overall 62 (15.8%) women expressed appreciations.

CONCLUSIONS

Collecting the women's views on how to improve the QMNC after hospital delivery highlighted critical inputs on aspects of care that should be improved in the opinion of service-users. More investments should be made for establishing routine systems for monitoring patients experience of care. Data collected should be used to improve QMNC. WHO Standards may be further optimized by adding items emerging as relevant for women in high-income countries.