Manifestations and drivers of mistreatment of women during childbirth in Kenya: implications for measurement and developing interventions

Factors influencing respectful perinatal care among healthcare professionals in low-and middle-resource countries: a systematic review

BACKGROUND

This review aimed to provide healthcare professionals with a scientific summary of best available research evidence on factors influencing respectful perinatal care. The review question was 'What were the perceptions of midwives and doctors on factors that influence respectful perinatal care?'

METHODS

A detailed search was done on electronic databases: EBSCOhost: Medline, OAlster, Scopus, SciELO, Science Direct, PubMed, Psych INFO, and SocINDEX. The databases were searched for available literature using a predetermined search strategy. Reference lists of included studies were analysed to identify studies missing from databases. The phenomenon of interest was factors influencing maternity care practices according to midwives and doctors. Pre-determined inclusion and exclusion criteria were used during selection of potential studies. In total, 13 studies were included in the data analysis and synthesis. Three themes were identified and a total of nine sub-themes.

RESULTS

Studies conducted in various settings were included in the study. Various factors influencing respectful perinatal care were identified. During data synthesis three themes emerged namely healthcare institution, healthcare professional and women-related factors. Alongside the themes were sub-themes human resources, medical supplies, norms and practices, physical infrastructure, healthcare professional competencies and attributes, women's knowledge, and preferences. The three factors influence the provision of respectful perinatal care; addressing them might improve the provision of this care.

CONCLUSION

Addressing factors that influence respectful perinatal care is vital towards the prevention of compromised patient care during the perinatal period as these factors have the potential to accelerate or hinder provision of respectful care.

A cluster randomized controlled trial to assess the impact of the 'Caring for Providers to Improve Patient Experience' intervention on person-centered maternity care in Kenya and Ghana: Study Protocol

Background

Poor person-centered maternal care (PCMC) contributes to high maternal mortality and morbidity, directly and indirectly, through lack of, delayed, inadequate, unnecessary, or harmful care. While evidence on poor PCMC prevalence, as well as inequities, expanded in the last decade, there is still a significant gap in evidence-based interventions to address PCMC. We describe the protocol for a trial to test the effectiveness of the "Caring for Providers to Improve Patient Experience" (CPIPE) intervention, which includes five strategies for provider behavior change, targeting provider stress and bias as intermediate factors to improve PCMC and to address inequities.

Methods

The trial will assess the effect of CPIPE on PCMC, as well as on intermediate and distal outcomes, using a two-arm cluster randomized controlled trial in 40 health facilities in Migori and Homa Bay Counties in Kenya and Upper East and Northeast Regions in Ghana. Twenty facilities in each country will be randomized to 10 intervention and 10 control sites. The primary intervention targets are all healthcare workers who provide maternal health services. The intervention impact will also be assessed first among providers, and then among women who give birth in health facilities. The primary outcome is PCMC measured with the PCMC scale, via multiple cross-sectional surveys of mothers who gave birth in the preceding 12 weeks in study facilities at baseline (prior to the intervention), midline (6 months after intervention start), and endline (12 months post-baseline) (N = 2000 across both countries at each time point). Additionally, 400 providers in the study facilities across both countries will be followed longitudinally at baseline, midline, and endline, to assess intermediate outcomes. The trial incorporates a mixed-methods design; survey data alongside in-depth interviews (IDIs) with healthcare facility leaders, providers, and mothers to qualitatively explore factors influencing the outcomes. Finally, we will collect process and cost data to assess intervention fidelity and cost-effectiveness.

Discussion

This trial will be the first to rigorously assess an intervention to improve PCMC that addresses both provider stress and bias and will advance the evidence base for interventions to improve PCMC and contribute to equity in maternal and neonatal health.

Mixed methods evaluation of the Caring for Providers to Improve Patient Experience intervention

OBJECTIVE

To assess the impact of the Caring for Providers to Improve Patient Experience (CPIPE) intervention, which sought to improve person-centered maternal care (PCMC) by addressing two key drivers: provider stress and bias.

METHODS

CPIPE was successfully piloted over 6 months in two health facilities in Migori County, Kenya, in 2022. The evaluation employed a mixed-methods pretest-posttest nonequivalent control group design. Data are from surveys with 80 providers (40 intervention, 40 control) at baseline and endline and in-depth interviews with 20 intervention providers. We conducted bivariate, multivariate, and difference-in-difference analysis of quantitative data and thematic analysis of qualitative data.

RESULTS

In the intervention group, average knowledge scores increased from 7.8 (SD = 2.4) at baseline to 9.5 (standard deviation [SD] = 1.8) at endline for stress (P = 0.001) and from 8.9 (SD = 1.9) to 10.7 (SD = 1.7) for bias (P = 0.001). In addition, perceived stress scores decreased from 20.9 (SD = 3.9) to 18.6 (SD = 5.3) (P = 0.019) and burnout from 3.6 (SD = 1.0) to 3.0 (SD = 1.0) (P = 0.001), with no significant change in the control group. Qualitative data indicated that CPIPE had an impact at multiple levels. At the individual level, it improved provider knowledge, skills, self-efficacy, attitudes, behaviors, and experiences. At the interpersonal level, it improved provider-provider and patient-provider relationships, leading to a supportive work environment and improved PCMC. At the institutional level, it created a system of accountability for providing PCMC and nondiscriminatory care, and collective action and advocacy to address sources of stress.

CONCLUSION

CPIPE impacted multiple outcomes in the theory of change, leading to improvements in both provider and patient experience, including for the most vulnerable patients. These findings will contribute to global efforts to prevent burnout and promote PCMC and equity.

Consented maternal care and associated factors among mothers who gave birth at public health institutions in South Wollo Zone, Amhara region, Ethiopia 2022

Introduction

Informed consent in healthcare services is a legal, ethical, and professional requirement on the part of all treating health providers and providing person-centered care. The methods of requesting consent during childbirth have not been extensively studied. In Ethiopia, there is not at all a single study done.

Objective

The purpose of this study is to determine associated factors among mothers who gave birth at health institutions in the South Wollo Zone, Amhara region, Ethiopia in 2022.

Methods

Mothers who gave birth at South Wollo Zone public health institutions, from 01 March to 30 April 2022 participated in a multi-center institutional-based cross-sectional study design. Systematic random sampling was used to select 423 study participants. A validated questionnaire was used for data collection, and the data were collected through face-to-face interviews. Data were entered into Epi-Data version 4.6 and exported to SPSS version 23 for analysis. A multivariable logistic regression analysis was performed to identify factors associated with the outcome variable. The level of significance was determined using an adjusted odds ratio with a 95% confidence interval.

Result

The study had 416 participants in total, with a response rate of 98.3%. Out of the 416 respondents interviewed, 67.1% of the women received consented care. The age group of 30-34, complications during childbirth, intended pregnancy, merchant, and primary and referral hospital were significantly associated with consented care.

Conclusion

The level of non-consented care during delivery was high compared with other literature reflecting substantial mistreatment. Therefore, stakeholders should strengthen monitoring and assessment systems to prevent abuse, and further study is required to look for practical ways to make improvements. Key elements of consented care have also been included in Basic and Emergency Obstetric Care training sessions and given to health providers.

Caring for providers to improve patient experience (CPIPE): intervention development process

A growing body of research has documented disrespectful, abusive, and neglectful treatment of women in facilities during childbirth, as well as the drivers of such mistreatment. Yet, little research exists on effective interventions to improve Person-Centred Maternal Care (PCMC)-care that is respectful and responsive to individual women's preferences, needs, and values. We sought to extend knowledge on interventions to improve PCMC, with a focus on two factors - provider stress and implicit bias - that are driving poor PCMC and contributing to disparities in PCMC. In this paper we describe the process towards the development of the intervention. The intervention design was an iterative process informed by existing literature, behaviour change theory, formative research, and continuous feedback in consultation with key stakeholders. The intervention strategies were informed by the Social Cognitive Theory, Trauma Informed System framework, and the Ecological Perspective. This process resulted in the 'Caring for Providers to Improve Patient Experience (CPIPE)' intervention, which has 5 components: provider training, peer support, mentorship, embedded champions, and leadership engagement. The training includes didactic and interactive content on PCMC, stress, burnout, dealing with difficult situations, and bias, with some content integrated into emergency obstetric and neonatal care (EmONC) simulations to enable providers apply concepts in the context of managing an emergency. The other components create an enabling environment for ongoing individual behavior and facility culture change. The pilot study is being implemented in Migori County, Kenya. The CPIPE intervention is an innovative theory and evidence-based intervention that addresses key drivers of poor PCMC and centers the unique needs of vulnerable women as well as that of providers. This intervention will advance the evidence base for interventions to improve PCMC and has great potential to improve equity in PCMC and maternal and neonatal health.

Adolescents' experience of mistreatment and abuse during childbirth: a cross-sectional community survey in a low-income informal settlement in Nairobi, Kenya

BACKGROUND

Adolescent girls in Africa have poorer maternal health outcomes than older women partly because they are less likely to access antenatal and facility-based delivery care. Mistreatment and abuse of adolescents during facility-based childbirth can further negatively impact their use of maternal healthcare services. Yet studies on this topic are limited. As a result, patterns of mistreatment and abuse, their association with care satisfaction, and the intention to use health facilities for future births or recommend facilities to others are poorly understood. This study estimates the prevalence of mistreatment and abuse of adolescent girls during facility-based childbirth in low-income settlements in an urban area. It also examines whether experiencing mistreatment and abuse during facility-based childbirth is associated with care satisfaction, willingness to recommend the facility to others, and intention to use the facility for subsequent childbirths.

METHODS

We used cross-sectional data collected from 491 adolescent mothers recruited through a household listing in an informal settlement in Nairobi, Kenya. Girls self-reported their experience of physical and verbal abuse, stigma and discrimination, lack of privacy, detainment (baby or mother detained in the clinic due to inability to pay user fees), neglect and abandonment during childbirth. Descriptive statistics were used to summarise the categorical variables while binary logistic regression models were used to examine the association between experience of mistreatment and abuse and care satisfaction, willingness to recommend the facility to others and intention to use the facility for subsequent childbirths.

RESULTS

About one-third of adolescent mothers (32.2%) reported physical abuse, verbal abuse or stigma and discrimination from health providers. 1 in 10 reported neglect and abandonment during childbirth, and about a quarter (24%) reported a lack of privacy. Detainment was reported by approximately 17% of girls. Report of any physical abuse, verbal abuse, and stigma and discrimination was significantly associated with a lower likelihood of satisfaction with care (Adjusted Odds ration (AOR) 0.24; 95% CI 0.15 to 0.38), intention to use the facility for future births (AOR 0.32; 95% CI 0.22 to 0.48) and willingness to recommend the facility to others (AOR 0.23; 95% CI 0.15 to 0.36). Neglect and abandonment during childbirth, and lack of privacy were significantly associated with lower odds of being satisfied with the care, intention to use the facility for future births, and the willingness to recommend the facility to others. Experience of detention was associated with a lower likelihood of intention to use the facility for future births (AOR 0.55; 95% CI 0.34 to 90), but not with the willingness to recommend the facility to others or overall satisfaction with care.

CONCLUSIONS

Mistreatment and abuse of adolescent girls during childbirth are common in the study setting and are associated with lower levels of satisfaction with care, intention to use the facility for future births, or recommend it to others. Preservice and in-service training of health workers in the study setting should address the need for respectful care for adolescents.

Implementing maternal and newborn health quality of care standards in healthcare facilities to improve the adoption of respectful maternity care in Bangladesh, Ghana and Tanzania: a controlled before and after study

INTRODUCTION

Many women worldwide cannot access respectful maternity care (RMC). We assessed the effect of implementing maternal and newborn health (MNH) quality of care standards on RMC measures.

METHODS

We used a facility-based controlled before and after design in 43 healthcare facilities in Bangladesh, Ghana and Tanzania. Interviews with women and health workers and observations of labour and childbirth were used for data collection. We estimated difference-in-differences to compare changes in RMC measures over time between groups.

RESULTS

1827 women and 818 health workers were interviewed, and 1512 observations were performed. In Bangladesh, MNH quality of care standards reduced physical abuse (DiD -5.2;-9.0 to -1.4). The standards increased RMC training (DiD 59.0; 33.4 to 84.6) and the availability of policies and procedures for both addressing patient concerns (DiD 46.0; 4.7 to 87.4) and identifying/reporting abuse (DiD 45.9; 19.9 to 71.8). The control facilities showed greater improvements in communicating the delivery plan (DiD -33.8; -62.9 to -4.6). Other measures improved in both groups, except for satisfaction with hygiene. In Ghana, the intervention improved women's experiences. Providers allowed women to ask questions and express concerns (DiD 37.5; 5.9 to 69.0), considered concerns (DiD 14.9; 4.9 to 24.9), reduced verbal abuse (DiD -8.0; -12.1 to -3.8) and physical abuse (DiD -5.2; -11.4 to -0.9). More women reported they would choose the facility for another delivery (DiD 17.5; 5.5 to 29.4). In Tanzania, women in the intervention facilities reported improvements in privacy (DiD 24.2; 0.2 to 48.3). No other significant differences were observed due to improvements in both groups.

CONCLUSION

Institutionalising care standards and creating an enabling environment for quality MNH care is feasible in low and middle-income countries and may facilitate the adoption of RMC.

Newcomer Women's Experiences with Perinatal Care During the Three-Month Health Insurance Waiting Period in Ontario, Canada

BACKGROUND

The three-month health insurance waiting period in Ontario reinforces health inequities for newcomer women and their babies. Little is known about the systemic factors that shape newcomer women's experiences during the OHIP waiting period.

PURPOSE

To examine the factors that shaped newcomer women's experiences with perinatal care during the three-month health insurance waiting period in Ontario, Canada.

METHODS

This qualitative study was informed by an intersectional framework, and guided by a critical ethnographic method. Individual interviews were conducted with four newcomer women and three perinatal healthcare professionals. Participant observations at recruitment and interview sites were integral to the study design.

RESULTS

The key systemic factors that shaped newcomer women's experiences with perinatal care included social identity, migration, and the healthcare system. Social identities related to gender, race, and socio-economic status intersected to form a social location, which converged with newcomer women's experiences of social isolation and exclusion. These experiences, in turn, intersected with Ontario's problematic perinatal health services. Together, these factors form systems of oppression for newcomer women in the perinatal period.

CONCLUSIONS

Given the health inequities that can result from these systems of oppression, it is important to adopt an upstream approach that is informed by the Human Rights Code of Ontario to improve accessibility to and the experiences of perinatal care for newcomer women.

Mistreatment of women during childbirth and its influencing factors in public maternity hospitals in Tehran, Iran: a multi-stakeholder qualitative study

BACKGROUND

Mistreatment during labour and childbirth is a common experience for many women around the world. This study aimed to explore the manifestations of mistreatment and its influencing factors in public maternity hospitals in Tehran.

METHODS

A formative qualitative study was conducted using a phenomenological approach in five public hospitals between October 2021 and May 2022. Sixty in-depth face-to-face interviews were conducted with a purposive sample of women, maternity healthcare providers, and managers. Data were analyzed with content analysis using MAXQDA 18.

RESULTS

Mistreatment of women during labour and childbirth was manifested in four form: (1) physical abuse (fundal pressure); (2) verbal abuse (judgmental comments, harsh and rude language, and threats of poor outcomes); (3) failure to meet professional standards of care (painful vaginal exams, neglect and abandonment, and refusal to provide pain relief); and (4) poor rapport between women and providers (lack of supportive care and denial of mobility). Four themes were also identified as influencing factors: (1) individual-level factors (e.g., providers' perception about women's limited knowledge on childbirth process), (2) healthcare provider-level factors (e.g., provider stress and stressful working conditions); (3) hospital-level factors (e.g., staff shortages); and (4) national health system-level factors (e.g., lack of access to pain management during labour and childbirth).

CONCLUSIONS

Our study showed that women experienced various forms of mistreatment during labour and childbirth. There were also multiple level drivers for mistreatment at individual, healthcare provider, hospital and health system levels. Addressing these factors requires urgent multifaceted interventions.

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

Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.

'I believe respect means providing necessary treatment on time' - a qualitative study of health care providers' perspectives on disrespect and abuse during childbirth in Southwest Ethiopia

BACKGROUND

The majority of maternal deaths occur in low-income countries, and facility-based childbirth is recognised as a strategy to reduce maternal mortality. However, experiences of disrespect and abuse during childbirth are reported as deterrents to women's utilisation of health care facilities. Health care providers play a critical role in women's experiences during childbirth; yet, there is limited research on service providers' views of disrespect and abuse in Ethiopia. Therefore, this study aimed to explore providers' perspectives on disrespect and abuse during childbirth in a teaching hospital in Southwest Ethiopia.

METHOD

Qualitative study was conducted in a tertiary teaching hospital in Jimma Ethiopia. In-depth interviews were conducted with 32 purposefully selected health care providers, including midwives, obstetrics and genecology resident's, senior obstetricians and nurses. Interviews were audio-recorded, transcribed and thematically analysed using the qualitative data analysis software program MAXQDA.

RESULTS

Three major themes were identified from the health care providers' perspectives: (1) respectful and abuse-free care, (2) recognised disrespect and abuse; and (3) drivers of women's feelings of disrespect and abuse. The first theme indicates that most of the participants perceived that women were treated with respect and had not experienced abuse during childbirth. The second theme showed that a minority of the participants recognised that women experienced disrespect and abuse during childbirth. The third theme covered situations in which providers thought that drivers for women felt disrespected.

CONCLUSION

Most providers perceived women's experiences as respectful, and they normalized, and rationalized disrespect and abuse. The effect of teaching environment, the scarcity of resources has been reported as a driver for disrespect and abuse. To ensure respectful maternity care, a collaborative effort of administrators, teaching institutions, professional associations and researchers is needed. Such collaboration is essential to create a respectful teaching environment, ensure availability of resources, sustained in-service training for providers, and establishing an accountability mechanism for respectful maternity care.

The Case for Using a Behavior Change Model to Design Interventions to Promote Respectful Maternal Care

Applying a behavior change framework to guide the design of interventions to improve respectful maternity care (RMC) could accelerate and unify the implementation and evaluation of diverse RMC interventions.

Are respectful maternity care (RMC) interventions effective in reducing intrapartum mistreatment against adolescents? A systematic review

Intrapartum mistreatment of women by health professionals is a widespread global public health challenge. It leads to a decreased quality of maternity care and is evinced to precipitate detrimental maternal and neonatal outcomes, especially among adolescents. Relatedly, research indicates that Respectful Maternity Care (RMC) interventions are especially effective in mitigating intrapartum mistreatment and improving birth outcomes. However, evidence on the success of RMC, specifically for adolescents, is insufficient and unaggregated. Accordingly, this review specifically aims to synthesize existing evidence on RMC care provision to adolescent parturients. This review searched for relevant literature from published and gray sources including PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, as well as Population Council, WHO and White Ribbon Alliance data sources published between January 1990 and December 2021. Based on eligibility, studies were selected and quality appraised after which thematic analysis and narrative synthesis was conducted. Twenty-nine studies were included in the systematic review. Due to paucity and heterogeneity of quantitative studies, the review was limited to a thematic analysis. Adolescent and health provider perspectives alike underscored the burden and outcomes of mistreatment. Need for RMC interventions to improve quality of maternity care was recommended by majority of studies.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42020183440.

Provider verbal disrespect in the provision of family planning in public-sector facilities in Western Kenya

Public-sector healthcare providers in low- and middle-income countries are a primary source of family planning but their disrespectful (i.e., demeaning or insulting) treatment of family planning clients may impede free contraceptive choice. The construct of disrespect and abuse has been widely applied to similar phenomena in maternity care and could help to better understand provider mistreatment of family planning clients. With a focus on public-sector family planning provision in western Kenya, we aim to estimate the prevalence and impact of disrespect and abuse from a variety of perspectives and advance methodological approaches to measuring this construct in the context of family planning provision. We combine and triangulate data from a variety of sources across five counties in western Kenya, including 180 mystery clients, 253 third-party observations, eight focus group discussions, 19 key informant interviews, and two journey mapping workshops. Across both mystery client and third-party observations conducted in public-sector facilities in western Kenya, approximately one out of every ten family planning seekers was treated with disrespect by their provider. Family planning clients were frequently scolded for seeking family planning while unmarried or low parity, but mistreatment was not limited to women with these specific characteristics. Women were also insulted for such characteristics as body size or perceived sexual promiscuity. Qualitative data confirmed both that client disrespect is widespread and leads women to avoid family planning services even when they desire to use a contraceptive method, sometimes leading to unintended pregnancies. Key informants attribute disrespectful provider practices to both low technical skill as well as poor motivation stemming from both intrinsic values as well as extrinsic factors such as low wages and high caseloads. Possible solutions suggested by key informants included changes to recruitment and admission for Kenyan medical/nursing schools, as well as values clarification to shift provider motivations. Interventions to reduce mistreatment must be multi-layered and well-evidenced to ensure that family planning clients receive the person-centered care that enables them to achieve their contraceptive desires and reproductive freedom.

A scoping review of the impact of organisational factors on providers and related interventions in LMICs: Implications for respectful maternity care

We have limited understanding of the organisational issues at the health facility-level that impact providers and care as it relates to mistreatment in childbirth, especially in low- and middle-income countries (LMICs). By extension, it is not clear what types of facility-level organisational changes or changes in working environments in LMICs could support and enable respectful maternity care (RMC). While there has been relatively more attention to health system pressures related to shortages of staff and other resources as key barriers, other organisational challenges may be less explored in the context of RMC. This scoping review aims to consolidate evidence to address these gaps. We searched literature published in English between 2000-2021 within Scopus, PubMed, Google Scholar and ScienceDirect databases. Study selection was two-fold. Maternal health articles articulating an organisational issue at the facility- level and impact on providers and/or care in an LMIC setting were included. We also searched for literature on interventions but due to the limited number of related intervention studies in maternity care specifically, we expanded intervention study criteria to include all medical disciplines. Organisational issues captured from the non-intervention, maternal health studies, and solutions offered by intervention studies across disciplines were organised thematically and to establish linkages between problems and solutions. Of 5677 hits, 54 articles were included: 41 non-intervention maternal healthcare studies and 13 intervention studies across all medical disciplines. Key organisational challenges relate to high workload, unbalanced division of work, lack of professional autonomy, low pay, inadequate training, poor feedback and supervision, and workplace violence, and these were differentially influenced by resource shortages. Interventions that respond to these challenges focus on leadership, supportive supervision, peer support, mitigating workplace violence, and planning for shortages. While many of these issues were worsened by resource shortages, medical and professional hierarchies also strongly underpinned a number of organisational problems. Frontline providers, particularly midwives and nurses, suffer disproportionately and need greater attention. Transforming institutional leadership and approaches to supervision may be particularly useful to tackle existing power hierarchies that could in turn support a culture of respectful care.

Experience of care of hospitalized newborns and young children and their parents: A scoping review

INTRODUCTION

Several global initiatives put parent involvement at the forefront of enabling children's well-being and development and to promote quality of care for newborns and hospitalized young children aged 0-24 months. Scanty evidence on mistreatment such as delays or neglect and poor pain management among newborns exists, with even less exploring the experience of their parents and their hospitalized young children. To address this gap, authors reviewed research on experience of care for hospitalized young children and their parents, and potential interventions that may promote positive experience of care.

METHODS

A scoping review of English language articles, guidelines, and reports that addressed the experiences of care for newborns and sick young children 0-24 months in health facilities was conducted. Multiple databases: PubMed, PROSPERO, COCHRANE Library and Google Scholar were included and yielded 7,784 articles. Documents published between 2009 and November 2020, in English and with evidence on interventions that addressed family involvement and partnership in care for their sick children were included.

RESULTS

The scoping review includes 68 documents across 31 countries after exclusion. Mistreatment of newborns comprises physical abuse, verbal abuse, stigma and discrimination, failure to meet professional standards, poor rapport between providers and patients, poor legal accountability, and poor bereavement and posthumous care. No literature was identified describing mistreatment of hospitalized children aged 60 days- 24 months. Key drivers of mistreatment include under-resourced health systems and poor provider attitudes. Positive experience of care was reported in contexts of good parent-provider communication. Three possible interventions on positive experience of care for hospitalized young children (0-24 months) emerged: 1) nurturing care; 2) family centered care and 3) provider and parental engagement. Communication and counseling, effective provider-parental engagement, and supportive work environments were associated with reduced anxiety and stress for parents and hospitalized young children. Few interventions focused on addressing providers' underlying attitudes and biases that influence provider behaviors, and how they affect engaging with parents.

CONCLUSION

Limited evidence on manifestations of mistreatment, lack of respectful care, drivers of poor experience and interventions that may mitigate poor experience of care for hospitalized young children 0-24 months especially in low resource settings exists. Design and testing appropriate models that enhance socio-behavioral dimensions of care experience and promote provider-family engagement in hospitals are required.

Exploring experiences with sensitivity to cultural practices among birth attendants in Kenya: A phenomenological study

Background

Aim

Setting

Methods

Results

Conclusion

Experiences and perceptions of care-seeking for febrile illness among caregivers, pregnant women, and health providers in eight districts of Madagascar

Background

Prompt diagnosis and treatment of malaria contributes to reduced morbidity, particularly among children and pregnant women; however, in Madagascar, care-seeking for febrile illness is often delayed. To describe factors influencing decisions for prompt care-seeking among caregivers of children aged < 15 years and pregnant women, a mixed-methods assessment was conducted with providers (HP), community health volunteers (CHV) and community members.

Methods

One health district from each of eight malaria-endemic zones of Madagascar were purposefully selected based on reported higher malaria transmission. Within districts, one urban and one rural community were randomly selected for participation. In-depth interviews (IDI) and focus group discussions (FGD) were conducted with caregivers, pregnant women, CHVs and HPs in these 16 communities to describe practices and, for HPs, system characteristics that support or inhibit care-seeking. Knowledge tests on malaria case management guidelines were administered to HPs, and logistics management systems were reviewed.

Results

Participants from eight rural and eight urban communities included 31 HPs from 10 public and 8 private Health Facilities (HF), five CHVs, 102 caregivers and 90 pregnant women. All participants in FGDs and IDIs reported that care-seeking for fever is frequently delayed until the ill person does not respond to home treatment or symptoms become more severe. Key care-seeking determinants for caregivers and pregnant women included cost, travel time and distance, and perception that the quality of care in HFs was poor. HPs felt that lack of commodities and heavy workloads hindered their ability to provide quality malaria care services. Malaria commodities were generally more available in public versus private HFs. CHVs were generally not consulted for malaria care and had limited commodities.

Conclusions

Reducing cost and travel time to care and improving the quality of care may increase prompt care-seeking among vulnerable populations experiencing febrile illness. For patients, perceptions and quality of care could be improved with more reliable supplies, extended HF operating hours and staffing, supportive demeanors of HPs and seeking care with CHVs. For providers, malaria services could be improved by increasing the reliability of supply chains and providing additional staffing. CHVs may be an under-utilized resource for sick children.

Absenteeism among family planning providers: a mixed-methods study in western Kenya

Public-sector healthcare providers are on the frontline of family planning service delivery in low- and middle-income countries like Kenya, yet research suggests public-sector providers are frequently absent. The current prevalence of absenteeism in Western Kenya, as well as the impact on family planning clients, is unknown. The objective of this paper is to quantify the prevalence of public-sector healthcare provider absenteeism in this region of Kenya, to describe the potential impact on family planning uptake and to source locally grounded solutions to provider absenteeism. We used multiple data collection methods including unannounced visits to a random sample of 60 public-sector healthcare facilities in Western Kenya, focus group discussions with current and former family planning users, key informant interviews (KIIs) with senior staff from healthcare facilities and both governmental and non-governmental organizations and journey mapping activities with current family planning providers and clients. We found healthcare providers were absent in nearly 60% of unannounced visits and, among those present, 19% were not working at the time of the visit. In 20% of unannounced visits, the facility had no providers present. Provider absenteeism took many forms including providers arriving late to work, taking an extended lunch break, not returning from lunch or being absent for the entire day. While 56% of provider absences resulted from sanctioned activities such as planned vacation, sick leave or off-site work responsibilities, nearly half of the absences were unsanctioned, meaning providers were reportedly running personal errands, intending to arrive later or no one at the facility could explain the absence. Key informants and focus group participants reported high provider absence is a substantial barrier to contraceptive use, but solutions for resolving this problem remain elusive. Identification and rigorous evaluation of interventions designed to redress provider absenteeism are needed.

"When You Have Gotten Help, That Means You Were Strong": A Qualitative Study of Experiences in a "Screen and Treat" Program for Cervical Cancer Prevention in Malawi

Disproportionate cervical cancer burden falls on women in low-income countries, and there are new efforts to scale up prevention worldwide, including via "screen and treat" for detection and removal of abnormal cervical lesions. This study examines Malawian women's experiences with "screen and treat"; this is an under-explored topic in the literature, which has focused largely on knowledge about and attitudes toward screening, but not on experiences with screening. We interviewed 47 women who have been screened at least once for cervical cancer. The interview guide and analysis approach were informed by the Multi-Level Health Outcomes Framework. Women were recruited at facilities that offer "screen and treat" and asked about their experiences with screening. The average age of respondents was 40 years, and approximately half were HIV-negative. Although women were knowledgeable about the benefits of screening, they articulated many barriers including being turned away because of stock-outs of equipment, far distances to services, discomfort with male providers, and poor communication with providers. Alongside the many health education campaigns to increase awareness and demand for "screen and treat" services, the global public health community must also address implementation barriers in the resource-constrained health systems where burden is greatest. Particular attention should be paid to quality and person-centeredness of "screen and treat" services to optimize uptake and engagement in care.

Health workers’ and hospital administrators’ perspectives on mistreatment of women during facility-based childbirth: a multicenter qualitative study in Ghana

Background

Globally, mistreatment of women during facility-based childbirth continues to impact negatively on the quality of maternal healthcare provision and utilization. The views of health workers are vital in achieving comprehensive understanding of mistreatment of women, and to design evidence-based interventions to prevent it. We explored the perspectives of health workers and hospital administrators on mistreatment of women during childbirth to identify opportunity for improvement in the quality of maternal care in health facilities.

Methods

A qualitative study comprising in-depth interviews (IDIs) with 24 health workers and hospital administrators was conducted in two major towns (Koforidua and Nsawam) in the Eastern region of Ghana. The study was part of a formative mixed-methods project to develop an evidence-based definition, identification criteria and two tools for measuring mistreatment of women in facilities during childbirth. Data analysis was undertaken based on thematic content via the inductive analytic framework approach, using Nvivo version 12.6.0.

Result

Health workers and hospital administrators reported mixed feelings regarding the quality of care women receive. Almost all respondents were aware of mistreatment occurring during childbirth, describing physical and verbal abuse and denial of preferred birthing positions and companionship. Rationalizations for mistreatment included limited staff capacity, high workload, perceptions of women’s non-compliance and their attitudes towards staff. Health workers had mixed responses regarding the acceptability of mistreatment of women, although most argued against it. Increasing staff strength, number of health facilities, refresher training for health workers and adequate education of women about pregnancy and childbirth were suggestions to minimize such mistreatment.

Conclusion

Health workers indicated that some women are mistreated during birth in the study sites and provided various rationalizations for why this occurred. There is urgent need to motivate, retrain or otherwise encourage health workers to prevent mistreatment of women and promote respectful maternity care. Further research on implementation of evidence-based interventions could help mitigate mistreatment of women in health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01372-3.

Respectful maternity care is vital to achieving positive pregnancy and childbirth experiences for women and their families. Mistreatment of women during childbirth at facilities can negatively impact women’s future health seeking behaviors and utilization of maternal care services. The experiences and perspectives of doctors, midwives and nurses working in labour wards are vital in understanding how women are treated during childbirth, and what measures can be taken to prevent it. In this study, we explored the opinions of health workers and hospital administrators on how women are treated during childbirth to determine the gaps in the quality of maternal care in health facilities in Ghana.

Participants expressed mixed feelings concerning mistreatment of women during childbirth. Most were aware of the occurrence of mistreatment in health facilities including physical and verbal abuse, and denial of preferred position for childbirth and companionship. The reasons provided for mistreatment included low staff capacity, high workload, non-compliance by women and poor attitudes towards health workers. Most health workers were against mistreatment during childbirth. Participants thought mistreatment could be minimized by improving staff skills, refresher training, and childbirth preparation education for women. Our study indicates the need to motivate, retrain or encourage health professionals to provide respectful care to women during childbirth to improve their experience of care. Further research to help implement better maternity care devoid of mistreatment in health facilities in Ghana is needed.

Adolescent experiences of mistreatment during childbirth in health facilities: secondary analysis of a community-based survey in four countries

INTRODUCTION

Pregnancy and childbearing among adolescents-especially younger adolescents-is associated with health complications and lost opportunities for education and personal development. In addition to established challenges adolescents and young women face in sexual and reproductive healthcare, evidence suggests that they also face mistreatment during childbirth.

METHODS

This is a secondary analysis of the WHO study 'How women are treated during facility-based childbirth' cross-sectional community survey in Ghana, Guinea, Myanmar and Nigeria. We used descriptive analysis to assess experiences of mistreatment among adolescents (15-19 years) and young women (20-24 years) and multivariable logistic regression models to assess the association between experiences of mistreatment and satisfaction with care during childbirth.

RESULTS

862 participants are included (15-19 years: 287, 33.3%; 20-24 years: 575, 66.7%). The most common mistreatment was verbal abuse (15-19 years: 104/287, 36.2%; 20-24 years: 181/575, 31.5%). There were high levels of poor communication (15-19 years: 92/287, 32.1%; 20-24 years: 171/575, 29.7%), lack of supportive care (15-19 years: 22/287, 42.5%; 20-24 years: 195/575, 33.9%) and lack of privacy (15-19 years: 180/287, 62.7%; 20-24 years: 395/575, 68.7%). Women who were verbally abused were less likely to report satisfaction with care (adjusted OR (AOR): 0.19, 95% CI: 0.12 to 0.31) and less likely to recommend the facility (AOR: 0.24, 95% CI: 0.15 to 0.38). There were similar reports among those who were physically abused, had long waiting time, did not mobilise and did not give consent for vaginal examinations.

CONCLUSION

Our study shows that adolescents and young women mistreatment during childbirth, contributing to low satisfaction with care. It is critical to recognise adolescents and young women's unique needs in maternal healthcare and how their needs may intersect with social stigma around sex and pregnancy.

Multistakeholder perspectives on the mistreatment of indigenous women during childbirth in Colombia: drivers and points for intervention

Background

Abusive and disrespectful treatment of women during childbirth is a critical global issue that threatens women’s sexual rights and reproductive rights and access to quality maternal care. This phenomenon has been documented in Colombia. However, little emphasis has been placed on identifying the drivers of and potential interventions against disrespect and abuse against particularly vulnerable populations in the country, including internally displaced indigenous women.

Methods

This report is a sub-analysis of a larger project. Semi-structured interviews were conducted with indigenous (Embera) women with childbirth experience (n = 10), maternal healthcare workers (n = 6), and community stakeholders (n = 5) in Medellín, Colombia. Qualitative analysis techniques, consisting of inductive and deductive approaches, were used to identify and characterize the drivers of disrespect and abuse against indigenous women during childbirth and points for intervention. Existing frameworks were adapted to thematically organize drivers and potential solutions into four interrelated subsystems: individual and community factors, clinician factors, facility factors, and national health system factors.

Results

Participants highlighted disrespect and abuse as stemming from (within the individual and community level) its normalization, lack of autonomy and empowerment among indigenous women, lacking antenatal care, (within the clinician level) prejudice, linguistic or cultural barriers to communication, lack of understanding of indigenous culture, medical culture and training, burnout and demoralization, (within the facility level) inadequate infrastructure, space, and human resources, and (within the national systems level) lack of clear policies and the devaluing of respectful maternity care. They called for interventions specific to these drivers, grounded in dignity and respect for indigenous culture.

Conclusion

This paper expands upon the growing literature on global mistreatment during childbirth by highlighting drivers of mistreatment and identifying points for intervention in a previously unstudied population. Our data show that indigenous women are especially vulnerable to mistreatment due to cultural and linguistic barriers and prejudice. Broad and meaningful action is urgently needed to realize these women’s rights to respectful maternity care. Interventions must be multifaceted and locally specific, taking into account the needs and wants of the women they serve.

Manifestations, responses, and consequences of mistreatment of sick newborns and young infants and their parents in health facilities in Kenya

Background

Despite efforts to incorporate experience of care for women and newborns in global quality standards, there are limited efforts to understand experience of care for sick newborns and young infants. This paper describes the manifestations, responses, and consequences of mistreatment of sick young infants (SYIs), drivers, and parental responses in hospital settings in Kenya.

Methods

A qualitative formative study to inform the development of strategies for promoting family engagement and respectful care of SYI was conducted in five facilities in Kenya. Data were collected from in-depth interviews with providers and policy makers (n = 35) and parents (n = 25), focus group discussions with women and men (n = 12 groups), and ethnographic observations in each hospital (n = 64 observation sessions). Transcribed data were organized using Nvivo 12 software and analyzed thematically.

Results

We identified 5 categories of mistreatment: 1) health system conditions and constraints, including a) failure to meet professional standards, b) delayed provision of care; and c) limited provider skills; 2) stigma and discrimination, due to provider perception of personal hygiene or medical condition, and patient feelings of abandonment; 3) physically inappropriate care, including providers taking blood samples and inserting intravenous lines and nasogastric tubes in a rough manner; or parents being pressured to forcefully feed infants or share unsterile feeding cups to avoid providers’ anger; 4) poor parental-provider rapport, expressed as ineffective communication, verbal abuse, perceived disinterest, and non-consented care; and 5) no organized form of bereavement and posthumous care in the case of infant’s death. Parental responses to mistreatment were acquiescent or non-confrontational and included feeling humiliated or accepting the situation. Assertive responses were rare but included articulating disappointment by expressing anger, and/or deciding to seek care elsewhere.

Conclusion

Mistreatment for SYIs is linked to poor quality of care. To address mistreatment in SYI, interventions that focus on building better communication, responding to the developmental needs of infants and emotional needs for parents, strengthen providers competencies in newborn care, as well as a supportive, enabling environments, will lead to more respectful quality care for newborns and young infants.

A qualitative exploratory interview study on birth companion support actions for women during childbirth

Background

The World Health Organization recommends that women are supported continuously throughout labor by a companion of their choice. And, that companions have clearly designated roles and responsibilities to ensure that their presence is beneficial to both the woman and her health care providers. Presently, there is lack of strong evidence regarding specific support actions in relation to women’s needs of care. Thus, we aimed to explore birth companion support actions for women during childbirth.

Methods

This was an exploratory descriptive qualitative study conducted between August 2019 and December 2019; at a referral hospital in the Eastern part of Uganda. Ten women were purposively selected: those who were admitted in early labor, expecting a normal delivery, and had fulltime birth companion. Nonparticipant direct observation and in-depth interviews were used to collect data. Latent content analysis was used.

Results

Three themes were identified: “Support actions aiding a good childbirth experience”, “Support actions hindering coping with labor”, and “Women’s needs and expectations of care”. Support actions aiding a good experience described were; emotional presence, motivation, providing nourishments, messenger activities, body massage for pain relief, assisting in ambulation and coaching. Companion fearful behaviors and disrespectful care in form of unacknowledged needs and hostility from birth companions were reported to hinder coping. The women desired thoughtful communication, trust, for birth companions to anticipate their needs and recognize non perceptive phases of labor to allow them focus on themselves.

Conclusion

Birth companions from this study largely supported women emotionally, and attended to their physical needs. The greater part of support actions provided were esteemed by the women. Presence of birth companion will be of benefit when individual needs of women are put into consideration. Also, more guidance for birth companions is necessary to boost their role and mitigate shortcomings of their presence during childbirth.

"You can't even ask a question about your child": Examining experiences of parents or caregivers during hospitalization of their sick young children in Kenya: A qualitative study

Background

Globally, about 5.2 million children under the age of five died in 2019, and more than half of those deaths occurred in Sub-Saharan Africa. In almost every death of a sick child, there is a parent/caregiver seeking health services for their child. This study sought to understand the experiences of care for parents/caregivers (caregivers) as they navigate the hospital system with the aim of identifying opportunities to improve service delivery and child health outcomes.

Methods

Qualitative data were collected from five hospitals in Kenya: three in Nairobi County and two in Bungoma County. Twenty-five in-depth interviews with caregivers (couples and single women) of young children 0-24 months old, 17 focus group discussions with women and men, and 64 institutional ethnographic observations were completed. Data were analyzed by initial annotation of transcripts and field materials, followed by open coding and thematic analysis using Nvivo 12 software. Summary themes were used to compare experiences between female and male caregivers, their child's age group, and study sites.

Results

Caregivers faced complex processes of care while seeking health services for their sick young children. Three overarching themes emerged with some variability across female and male caregiver perspectives: (1) Navigating structural issues: long wait times, confusing payment mechanisms, overcrowding, unhygienic conditions, and strict visitation policies; (2) Interactions with providers: positive experiences, including providers showing empathy and concern, and negative experiences of harsh language, neglect, lack of privacy, discounting caregiver perspectives, and not involving men; Limited communication between caregivers and providers on child's diagnosis, treatment, and progress and lack of communication specifically between male caregivers and providers; and (3) Limited emotional support for both caregivers during difficult diagnosis or bereavement.

Conclusions

To improve experiences, interventions, programs, and policies need to focus on good provider-caregiver partnerships; enhancing opportunities for male engagement, such as supportive visiting hours; effective communication between caregivers and providers; access to adequate emotional support; and an enabling hospital environment.

Health system bottlenecks hindering provision of supportive and dignified maternity care in public health facilities

Mistreatment with women during childbirth is prevalent in many in low- and middle-income countries. There is dearth of evidence that informs development of health system interventions to promote supportive and respectful maternity care in facility-based settings. We examined health systems bottlenecks that impedes provision of supportive and respectful maternity care in secondary-level public healthcare system of Pakistan. Using a qualitative exploratory design, forty in-depth interviews conducted with maternity care staff of six public health facilities in southern Pakistan. Development of interview guide and data analyses were guided by the WHO's six health system building blocks. A combination of inductive and deductive approach was used for data analyses. Our study identified range of bottlenecks impeding provision of RMC. In terms of leadership/governance, there was lack of institutional guidelines, supervision and monitoring, and patient feedback mechanism. No systematic mechanism existed to screen and record patient psychosocial needs. Health workforce lacked training opportunities on RMC that resulted in limited knowledge and skills; there were also concerns about lack of recognition from leadership for good performers, and poor relationship and coordination between clinical and non-clinical staff. Regarding the domain of service delivery, we found that patients were perceived as un-cooperative, non-RMC manifestations were acceptable and normalized under certain conditions, and restrictive policies for active engagement of companions. Finally, lack of cleanliness, curtains for privacy, seating arrangement for companion were the identified issues infrastructural issues. A service-delivery intervention package is needed that effectively uses all six components of the health system: from investments in capacity building of maternity teams to creating a conducive facility environment via proper governance and accountability mechanisms. Such interventions should not only focus on provision of maternity care in a respectful and dignified manner, but also ensure that care is responsive to the psychosocial needs of pregnant women without any discrimination.

Health workers' disrespectful and abusive behaviour towards women during labour and delivery: A qualitative study in Durban, South Africa

BACKGROUND

A high prevalence of disrespectful and abusive behaviour by health workers towards women during labour and delivery has been widely described in health facilities, particularly in Africa, and is a worldwide public health concern. Such behaviours are barriers to care-seeking, and are associated with adverse outcomes for mothers and newborns. This paper reports experiences of disrespectful care among informal working women in three public health facilities in Durban, South Africa.

METHODS

A qualitative longitudinal study was conducted among a cohort of informal working women recruited during pregnancy in two clinics in Durban. The study comprised a series of in-depth interviews conducted at different time points from pregnancy until mothers had returned to work, followed by focus group discussions (FGDs) with cohort participants. We present data from participatory FGDs, known as 'Journey with my Baby', conducted at the end of the study, during which women's experiences from pregnancy until returning to work were reviewed and explored. Thematic analysis was used with NVIVO v12.4.

RESULTS

Three 'Journey with my Baby' FGDs were conducted with a total of 15 participants between March and October 2019. Many participants narrated experiences of disrespectful behavior from nurses during labour and childbirth, with several women becoming very distressed as a result. Women described experiencing rudeness and verbal abuse from nurses, lack of privacy and confidentiality, nurses refusing to provide care, being denied companionship and being left unattended for long periods during labour. Women described feeling anxious and unsafe while in the labour ward because of the behaviour they experienced directly and observed other patients experiencing. Such experiences created bad reputations for health facilities, so that women in the local community were reluctant to attend some facilities.

CONCLUSION

Disrespect and abuse continues to be a serious concern in public health facilities in South Africa. We challenge the health system to effectively address the underlying causes of disrespectful behavior among health workers, initiate robust monitoring to identify abusive behavior when it occurs, and take appropriate actions to ensure accountability so that women receive the high-quality maternity care they deserve.

Care Providers' Perspectives on Disrespect and Abuse of Women During Facility-Based Childbirth in Ethiopia: A Qualitative Study

Background

It is increasingly evident that disrespect and abuse of women during facility-based childbirth is a violation of a woman’s rights and a deterrent to the use of life-saving maternity care. Understanding care providers’ perspectives of disrespect and abuse during facility-based childbirth is an essential element to aid in fully comprehending the problem and its underlying complexities.

Objective

To explore care providers’ perspectives of disrespect and abuse during facility-based childbirth.

Methods

This study used a qualitative descriptive design involving fifteen in-depth, semi-structured, interviews conducted between 5 October 2019 and 25 January 2020 in north Showa zone of Oromia region, central Ethiopia. Purposive sampling enabled health care professionals working in maternity units of health facilities who have direct involvement in care of women during pregnancy and labor to be recruited. Thematic analysis using Open Code software was used to explore the perspectives of participants.

Results

Four themes were identified. 1) Disrespect and abuse breaches professional standards, 2) Disrespectful and abusive actions are justified at times to save the mother and her baby, 3) Disrespect and abuse is used as a tool to assert power, and 4) Disrespect and abuse arise from health system deficiencies.

Conclusion

Disrespect and abuse is triggered by underlying beliefs about risk versus care, provider attitudes, stress and burnout, and health service structural issues including a lack of medicines and supplies. A number of strategies could improve the quality of maternity care, including training providers how to manage difficult and complex situations, addressing root causes of disrespect and abuse, and increasing access to resources.

Self-reported provision of person-centred maternity care among providers in Kenya and Ghana: scale validation and examination of associated factors

INTRODUCTION

Person-centred maternity care (PCMC), which refers to care that is respectful and responsive to women's preferences needs, and values, is core to high-quality maternal and child health. Provider-reported PCMC provision is a potentially valid means of assessing the extent of PCMC and contributing factors. Our objectives are to assess the psychometric properties of a provider-reported PCMC scale, and to examine levels and factors associated with PCMC provision.

METHODS

We used data from two cross-sectional surveys with 236 maternity care providers from Ghana (n=150) and Kenya (n=86). Analysis included factor analysis to assess construct validity and Cronbach's alpha to assess internal consistency of the scale; descriptive analysis to assess extent of PCMC and bivariate and multivariable linear regression to examine factors associated with PCMC.

FINDINGS

The 9-item provider-reported PCMC scale has high construct validity and reliability representing a unidimensional scale with a Cronbach's alpha of 0.72. The average standardised PCMC score for the combined sample was 66.8 (SD: 14.7). PCMC decreased with increasing report of stress and burnout. Compared with providers with no burnout, providers with burnout had lower average PCMC scores (β: -7.30, 95% CI:-11.19 to -3.40 for low burnout and β: -10.86, 95% CI: -17.21 to -4.51 for high burnout). Burnout accounted for over half of the effect of perceived stress on PCMC.

CONCLUSION

The provider PCMC scale is a valid and reliable measure of provider self-reported PCMC and highlights inadequate provision of PCMC in Kenya and Ghana. Provider burnout is a key driver of poor PCMC that needs to be addressed to improve PCMC.

Evidence on respectful maternity care for adolescents: a systematic review protocol

BACKGROUND

Intrapartum mistreatment of women is an ubiquitous public health and human rights challenge. The issue reportedly has severe maternal and neonatal outcomes including mortality, and generally leads to a decreased satisfaction with maternity care. Intrapartum mistreatment, despite being ubiquitous, indicates higher incidence amongst adolescent parturients who are simultaneously at a higher risk of maternal morbidity and mortality. Studies have suggested that Respectful Maternity Care interventions reduce intrapartum mistreatment and improve clinical outcomes for women and neonates in general. However, evidence on the effect of RMC on adolescents is unclear. Hence, the specific aim of this study is to synthesise the available evidence relating to the provision of RMC for adolescents during childbirth.

METHODS

The methodology of the proposed systematic review follows the procedural guideline depicted in the preferred reporting items for systematic review protocol. The review will include published studies and gray literature from January 1, 1990, to June 30, 2021. Electronic databases including MEDLINE, PubMed, ScienceDirect, Cochrane, CINAHL, PsycINFO, Scopus, Google Scholar and Web of Science will be searched to retrieve available studies using the appropriate search strings. Studies included in the review will be appraised for quality using tools tailored to each study design. If appropriate, we will conduct random effects meta-analysis of data to summarise the pooled estimates of respectful maternity care prevalence and outcomes. The selection of relevant studies, data extraction and quality assessment of individual studies will be carried out by two independent authors.

RESULTS

Summaries of the findings will be compiled and synthesised in a narrative summary. In addition to the narrative synthesis, where sufficient data are available, a random-effects meta-analysis will be conducted to obtain a pooled estimate value for respectful maternity care prevalence and outcomes.

DISCUSSION

Respectful Maternity Care for adolescents holds great promise for improved maternal and neonatal care. However, there is a gap in knowledge on the interventions that work and the extent of their effectiveness. Findings from this study will be beneficial in improving Adolescents Sexual and Reproductive Health and Rights and reducing maternal mortality, especially for adolescents.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020183440.

Examining person-centered maternity care in a peri-urban setting in Embakasi, Nairobi, Kenya

INTRODUCTION

Peri-urban settings have high maternal mortality and the quality of care received in different types of health facilities is varied. Yet few studies have explored the construct of person-centered maternity care (PCMC) within peri-urban settings. Understanding women's experience of maternity care in peri-urban settings will allow health facility managers and policy makers to improve services in these settings. This study examines factors associated with PCMC in a peri-urban setting in Kenya.

METHODS AND MATERIALS

We analyzed data from a cross-sectional study with 307 women aged 18-49 years who had delivered a baby within the preceding six weeks. Women were recruited from public (n = 118), private (n = 76), and faith based (n = 113) health facilities. We measured PCMC using the 30-item validated PCMC scale which evaluates women's experiences of dignified and respectful care, supportive care, and communication and autonomy. Factors associated with PCMC were evaluated using multilevel models, with women nested within facilities.

RESULTS

The average PCMC score was 58.2 (SD = 13.66) out of 90. Controlling for other factors, literate women had, on average, about 6-point higher PCMC scores than women who were not literate (β = 5.758, p = 0.006). Women whose first antenatal care (ANC) visit was in the second (β = -5.030, p = 0.006) and third trimester (β = -7.288, p = 0.003) had lower PCMC scores than those whose first ANC were in the first trimester. Women who were assisted by an unskilled attendant or an auxiliary nurse/midwife at birth had lower PCMC than those assisted by a nurse, midwife or clinical officer (β = -8.962, p = 0.016). Women who were interviewed by phone (β = -7.535, p = 0.006) had lower PCMC scores than those interviewed in person.

CONCLUSIONS

Factors associated with PCMC include literacy, ANC timing and duration, and delivery provider. There is a need to improve PCMC in these settings as part of broader quality improvement activities to improve maternal and neonatal health.

Does institutional maternity services contribute to the fear of childbirth? A focus group interview study

BACKGROUND

The quality of institutional maternity services offered significantly determine the health outcomes of pregnant women and their infants.

OBJECTIVES

The study aimed at understanding perceptions and experiences of new mothers diagnosed with the fear of childbirth in Kenya; regarding the institutional maternity services offered and if they contribute to the fear of childbirth (FOC).

METHODS

This was a qualitative descriptive study. A total of 29 women who had given birth recently in a maternity institution, and had been screened with the fear of childbirth at 32 weeks' gestation period participated in focus group interviews. The Framework for Assessing the Quality of Care of institutional maternity services (FAQC) developed by the University of Southampton was adopted in this study. Thematic analyses were used.

RESULTS

It was reported that institutional maternity services contributed directly and indirectly to FOC. The direct contribution included the performance of unintended caesarian sections, severe and prolonged labour pains and negative attitude of healthcare providers. The indirect contribution was in form of challenges in the provision of care and the experience of care in the maternity institutions. In the provision of care; human and physical resources, inadequate referral systems, and inadequate management of emergencies were reported. In the experience of care; lack of cognition, respect, dignity, equity and inadequacies in emotional support were reported.

CONCLUSION

The study identified systemic challenges related to both the provision and the experience of care. Therefore, there is need to astutely analyze all critical steps identified in the FAQC, as this will greatly improve the uptake of institutional maternity services.

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.

Women's report of mistreatment during facility-based childbirth: validity and reliability of community survey measures

Background

Accountability for mistreatment during facility-based childbirth requires valid tools to measure and compare birth experiences. We analyse the WHO ‘How women are treated during facility-based childbirth’ community survey to test whether items mapping the typology of mistreatment function as scales and to create brief item sets to capture mistreatment by domain.

Methods

The cross-sectional community survey was conducted at up to 8 weeks post partum among women giving birth at hospitals in Ghana, Guinea, Myanmar and Nigeria. The survey contained items assessing physical abuse, verbal abuse, stigma, failure to meet professional standards, poor rapport with healthcare workers, and health system conditions and constraints. For all domains except stigma, we applied item-response theory to assess item fit and correlation within domain. We tested shortened sets of survey items for sensitivity in detecting mistreatment by domain. Where items show concordance and scale reliability ≥0.60, we assessed convergent validity with dissatisfaction with care and agreement of scale scores between brief and full versions.

Results

2672 women answered over 70 items on mistreatment during childbirth. Reliability exceeded 0.60 in all countries for items on poor rapport with healthcare workers and in three countries for items on failure to meet professional standards; brief scales generally showed high agreement with longer versions and correlation with dissatisfaction. Brief item sets were ≥85% sensitive in detecting mistreatment in each country, over 90% for domains of physical abuse and health system conditions and constraints.

Conclusion

Brief scales to measure two domains of mistreatment are largely comparable with longer versions and can be informative for these four distinct settings. Brief item sets efficiently captured prevalence of mistreatment in the five domains analysed; stigma items can be used and adapted in full. Item sets are suitable for confirmation by context and implementation to increase accountability and inform efforts to eliminate mistreatment during childbirth.

An innovative intervention to improve respectful maternity care in three Districts in Ethiopia

BACKGROUND

Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions.

METHODS

Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data.

RESULTS

Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations.

CONCLUSION

This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

Understanding disparities in person-centred maternity care: the potential role of provider implicit and explicit bias

Studies in low-resource settings have highlighted disparities in person-centred maternity care (PCMC)-respectful and responsive care during childbirth-based on women's socioeconomic status (SES) and other characteristics. Yet few studies have explored factors that may underlie these disparities. In this study, we examined implicit and explicit SES bias in providers' perceptions of women's expectations and behaviours, as well as providers' general views regarding factors influencing differential treatment of women. We conducted a convergent mixed-methods study with 101 maternity providers in western Kenya. Implicit SES bias was measured using an adaptation of the Implicit Association Test (IAT) and explicit SES bias assessed using situationally specific vignettes. Qualitative data provided additional details on the factors contributing to disparities. Results provide evidence for the presence of both implicit and explicit bias related to SES that might influence PCMC. Differential treatment was linked to women's appearance, providers' perceptions of women's attitudes, assumptions about who is more likely to understand or be cooperative, women's ability to advocate for themselves or hold providers accountable, ability to pay for services in a timely manner, as well as situational factors related to stress and burnout. These factors interact in complex ways to produce PCMC disparities, and providing better care to certain groups does not necessarily indicate preference for those groups or a desire to provide better care to them. The findings imply the need for multilevel approaches to addressing disparities in maternity care. This should include provider training on PCMC and their biases, advocacy for women of low SES, accountability mechanisms, and structural and policy changes within health care settings.

Care providers' perspectives on disrespect and abuse of women during facility-based childbirth in Africa: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to identify and synthesize the best available qualitative evidence to understand healthcare providers' views on disrespect and abuse of women during facility-based childbirth in Africa.

INTRODUCTION

Everyday, approximately 800 women die from preventable pregnancy- and childbirth-related causes worldwide; poorer women living in developing countries comprise 99% of these deaths. Maternal mortality has no single cause or solution, but the most effective preventive strategy is ensuring that every woman gives birth in an equipped health facility with the help of skilled providers. Yet, many women decline to attend facility-based delivery, often due to disrespect and abuse received during childbirth.

INCLUSION CRITERIA

This systematic review will consider studies that include views of care providers regarding disrespect and abuse of women in birthing facilities, including verbal, physical and sexual abuse; stigma; discrimination; substandard care; neglect; and trust and communication problems. Qualitative studies that relate to Africa published in English from 1990 will be included.

METHODS

PubMed, CINAHL, Embase, Scopus, African Index Medicus and Web of Science, and selected gray literature sources, will be searched for eligible papers. Titles and abstracts of obtained documents will be assessed by the lead reviewer against the inclusion criteria. Identified documents will then be appraised for relevance and rigor by two independent reviewers. Data will be extracted by two independent reviewers and graded according to the ConQual approach.

Is the Training, Knowledge, and Perception of Maternal Health Providers Adequate for the Provision of Respectful Maternity Care? Policy Implications for Practice in a Nigerian Tertiary Hospital

Background

Health providers play pivotal roles in achieving respectful maternity care (RMC). This study assessed the training, knowledge, and perception of respectful maternity care among maternal health providers in a Nigerian tertiary hospital.

Methodology

This was across-sectional study conducted among 156 maternal health providers in Ebonyi Nigeria. Self-administered questionnaires were used for data collection.

Results

The respondents had a mean age of 31.97±6. 8years. Females constituted 35.9% of the respondents while 25.6% were midwives. Less than half had received undergraduate (48.7%) and postgraduate (42.3%) training on RMC. The majority were aware (72.4%) and had good knowledge (78.8%) of respectful maternity care. Medical books (33.3%) was the major source of information on RMC. Most respondents (90.4%) desired more education on RMC. Over four-fifths (82.1%) had a positive perception of RMC. Only 27.6% of respondents agreed that mistreatment during childbirth was a common phenomenon in their clinical practice context. About three-fourths (76.6%) did not agree that mistreatment during childbirth was harmful to maternal health. Undergraduate training on RMC (AOR=0.33, 95% CI=0.13-0.81), postgraduate training on RMC (AOR=0.30, 95% CI=0.11-0.82) and higher monthly income (AOR=0.20 95% CI=0.05-0.88) were predictors of awareness of RMC. Knowledge of RMC was a predictor of perception about RMC (AOR=0.29, 95% CI=0.11-0.71).

Conclusion

There was good awareness, knowledge and perception of RMC predicted by training exposures and income status However, gaps existed in the perception of the occurrence and consequences of mistreatment during childbirth. We recommend the inclusion of RMC training in both undergraduate and postgraduate medical training curricula.

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.

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.

The relationship between inequitable gender norms and provider attitudes and quality of care in maternal health services in Rwanda: a mixed methods study

Background

Rwanda has made great progress in improving reproductive, maternal, and newborn health (RMNH) care; however, barriers to ensuring timely and full RMNH service utilization persist, including women’s limited decision-making power and poor-quality care. This study sought to better understand whether and how gender and power dynamics between providers and clients affect their perceptions and experiences of quality care during antenatal care, labor and childbirth.

Methods

This mixed methods study included a self-administered survey with 151 RMNH providers with questions on attitudes about gender roles, RMNH care, provider-client relations, labor and childbirth, which took place between January to February 2018. Two separate factor analyses were conducted on provider responses to create a Gender Attitudes Scale and an RMNH Quality of Care Scale. Three focus group discussions (FGDs) conducted in February 2019 with RMNH providers, female and male clients, explored attitudes about gender norms, provision and quality of RMNH care, provider-client interactions and power dynamics, and men’s involvement. Data were analyzed thematically.

Results

Inequitable gender norms and attitudes – among both RMNH care providers and clients – impact the quality of RMNH care. The qualitative results illustrate how gender norms and attitudes influence the provision of care and provider-client interactions, in addition to the impact of men’s involvement on the quality of care. Complementing this finding, the survey found a relationship between health providers’ gender attitudes and their attitudes towards quality RMNH care: gender equitable attitudes were associated with greater support for respectful, quality RMNH care.

Conclusions

Our findings suggest that gender attitudes and power dynamics between providers and their clients, and between female clients and their partners, can negatively impact the utilization and provision of quality RMNH care. There is a need for capacity building efforts to challenge health providers’ inequitable gender attitudes and practices and equip them to be aware of gender and power dynamics between themselves and their clients. These efforts can be made alongside community interventions to transform harmful gender norms, including those that increase women’s agency and autonomy over their bodies and their health care, promote uptake of health services, and improve couple power dynamics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03592-0.

Do you need to pay for quality care? Associations between bribes and out-of-pocket expenditures on quality of care during childbirth in India

While it is mandated that reproductive and child health services be provided for free at public facilities in India, qualitative evidence suggests it is common for facilities to request bribes and other informal payments for medicines, medical tests or equipment. This article examines the prevalence of bribe requests, total out-of-pocket expenditures (OOPEs) and associations between bribe requests and total OOPEs on the experience of quality of care and maternal complications during childbirth. Women who delivered in public facilities in Uttar Pradesh, India were administered a survey on sociodemographic characteristics, bribe requests, total OOPEs, types of health checks received and experience of maternal complications. Data were analysed using descriptive, bivariate and multivariate statistics. Among the 2018 women who completed the survey, 43% were asked to pay a bribe and 73% incurred OOPEs. Bribe requests were associated with lower odds of receiving all health checks upon arrival to the facility (aOR = 0.49; 95% CI: 0.24-0.98) and during labour and delivery (aOR = 0.44; 95% CI: 0.25-0.76), lower odds of receiving most or all health checks after delivery (aOR = 0.44; 95% CI: 0.31-0.62) and higher odds of experiencing maternal complications (aOR = 1.45; 95% CI: 1.13-1.87). Although it is mandated that maternity care be provided for free in public facilities in India, these findings suggest that OOPEs are high, and bribes/tips contribute significantly. Interventions centred on improving person-centred care (particularly guidelines around bribes), health system conditions and women's expectations of care are needed.

Providers' perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya

Disrespect and abuse during childbirth are violations of women's human rights and an indicator of poor-quality care. Disrespect and abuse during childbirth are widespread, yet data on providers' perspectives on the topic are limited. We examined providers' perspectives on the frequency and drivers of disrespect and abuse during facility-based childbirth in a rural county in Kenya. We used data from a mixed-methods study in a rural county in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical) in 2016. Providers were asked structured questions on disrespect and abuse, followed by open-ended questions on why certain behaviours were exhibited (or not). Most providers reported that women were often treated with dignity and respect. However, 53% of providers reported ever observing other providers verbally abuse women and 45% reported doing so themselves. Observation of physical abuse was reported by 37% of providers while 35% reported doing so themselves. Drivers of disrespect and abuse included perceptions of women being difficult, stress and burnout, facility culture and lack of accountability, poor facility infrastructure and lack of medicines and supplies, and provider attitudes. Provider bias, training and women's empowerment influenced how different women were treated. We conclude that disrespect and abuse are driven by difficult situations in a health system coupled with a facilitating sociocultural environment. Providers resorted to disrespect and abuse as a means of gaining compliance when they were stressed and feeling helpless. Interventions to address disrespect and abuse need to tackle the multiplicity of contributing factors. These should include empowering providers to deal with difficult situations, develop positive coping mechanisms for stress and address their biases. We also need to change the culture in facilities and strengthen the health systems to address the system-level stressors.

Providing respectful maternity care in northern Ghana: A mixed-methods study with maternity care providers

OBJECTIVE

This study explored providers' perspectives and behavior regarding respectful maternity care, including knowledge, attitudes, and practices.

DESIGN

Mixed-methods cross-sectional study combining quantitative survey data, qualitative interviews, and observations of labor and delivery across four health facilities SETTING: Government health facilities in rural northern Ghana PARTICIPANTS: 43 front-line maternity care providers completed a survey of practice patterns before a quality of care training. We then used purposive and convenience sampling to recruit a sub-sample for in-depth interviews (N=17), and convenience sampling and self-selection to observe approximately half (N=8) providing clinical care.

MEASUREMENTS AND FINDINGS

We calculated descriptive statistics from quantitative data and used the framework approach for qualitative analysis. Observational data were examined using the CHANGE Project's Assessment Tools for Caring Providers. We utilized split frame methodology to make comparisons across data sources. Quantitative survey results (N=43) indicate most providers report explaining procedures to women (89.5%), involving women and families in care decisions (84.1%), and covering or screening women for privacy (81.5%). At the same time, 38.9% reported they have shouted at, scolded, insulted, threatened, or talked rudely to a woman, and 26.4% said they have treated a woman differently because of her personal attributes. Qualitative interview data (N=17) suggested that providers can articulate a vision of respectful care, aspire to offer respectful care, and recognize they do not always meet those aspirations. Among those (N=8) volunteering to be observed, introductions and explanations for procedures were rare, privacy screening was infrequent, and participants were observed slapping, scolding, and restraining women in labor, often associated with patient non-compliance to provider instructions.

KEY CONCLUSIONS

Even among providers knowledgeable about respectful maternity care and who agreed to be observed providing delivery care, disrespect and abuse were present.

IMPLICATIONS FOR PRACTICE

Further research and programmatic efforts are needed to address the gap between knowledge and behavior.

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.

Multi-stakeholder Perspectives on the Maternal, Provider, Institutional, Community, and Policy Drivers of Disrespectful Maternity Care in South-East Nigeria

Purpose

Understanding the contextualized perspectives of stakeholders involved in maternal health care is critical to promoting respectful maternity care. This study explored maternal, provider, institutional, community, and policy level drivers of disrespectful maternity care in Southeast Nigeria. This study also identified multi-stakeholder perspectives on solutions to implementing respectful maternity care in health facilities.

Materials and Methods

This was a mixed-methods cross-sectional study conducted in two urban cities of Ebonyi State, South-eastern Nigeria. Data were collected using semi-structured questionnaires, focus group discussions, and key informant interviews with mothers, providers, senior facility obstetric decision-makers, ministry of health policymaker, and community members. Quantitative data and qualitative data were analysed using SPSS version 20 and manual thematic analysis, respectively.

Results

Maternal level drivers were poor antenatal clinic attendance, uncooperative clients, non-provision of birthing materials, and low awareness of rights. Provider factors included work overload/stress, training gaps, desire for good obstetric outcome, under-remuneration and under-appreciation. Institutional drivers were poor work environments including poorly designed wards for privacy, stressful hospital protocols, and non-provision of work equipment. Community-level drivers were poor female autonomy, empowerment, and normalization of disrespect and abuse during childbirth. The absence of targeted policies and the high cost of maternal health services were identified as policy-related drivers.

Conclusion

A variety of multi-level drivers of disrespectful maternity care were identified. A diverse and inclusive multi-stakeholder approach should underline efforts to mitigate disrespectful maternity care and promote respectful, equitable, and quality maternal health care.

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.