Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care

"If I am alive, I am happy": Defining quality of care from the perspectives of key maternal and newborn health stakeholders in Papua New Guinea

Quality maternal and newborn healthcare is essential to improve experiences and health outcomes for mothers and babies. In many low to middle income countries, such as Papua New Guinea, there are initiatives to increase antenatal care attendance and facility births. To develop and implement initiatives that are appropriate, relevant, and contextualised to a community, it is important to understand how quality of care is perceived and defined by different maternal and newborn healthcare stakeholders. The aim of this study was to understand how women, their partners, healthcare professionals, healthcare managers, and provincial health administrators in East New Britain, Papua New Guinea define quality of pregnancy, childbirth, and immediate postnatal care. An exploratory qualitative study underpinned by a partnership-defined quality approach was undertaken. In total, 42 participants from five different healthcare facilities in East New Britain, Papua New Guinea, were interviewed. These included women, partners, healthcare professionals, healthcare managers, and provincial health administrators. Interviews were analysed using thematic analysis, assisted by NVivo computer software. Four themes were identified aligning with the journey a woman takes throughout the health system. These included (I) Ensuring Access: Arriving at the health centre, (II) Experiencing Positive Care: What the staff do, (III) Having the Bare Minimum: Resources available to the service, and (IV) Meeting Expectations: Outcomes of care. Stakeholder groups had significant overlap in how quality of care was defined, however women and partners focussed more on elements relating to experience of care, while clinical stakeholders focussed on elements relating to provision of care. There is a gap in how stakeholders define quality maternal and newborn healthcare, and the quality of the care which is administered and received.

Women's experience of childbirth care in health facilities: a qualitative assessment of respectful maternity care in Afghanistan

BACKGROUND

Respectful maternity care (RMC) remains a key challenge in Afghanistan, despite progress on improving maternal and newborn health during 2001-2021. A qualitative study was conducted in 2018 to provide evidence on the situation of RMC in health facilities in Afghanistan. The results are useful to inform strategies to provide RMC in Afghanistan in spite of the humanitarian crisis due to Taliban's takeover in 2021.

METHODS

Focus group discussions were conducted with women (4 groups, 43 women) who had used health facilities for giving birth and with providers (4 groups, 21 providers) who worked in these health facilities. Twenty key informant interviews were conducted with health managers and health policy makers. Motivators for, deterrents from using, awareness about and experiences of maternity care in health facilities were explored.

RESULTS

Women gave birth in facilities for availability of maternity care and skilled providers, while various verbal and physical forms of mistreatment were identified as deterrents from facility use by women, providers and key informants. Low awareness, lack of resources and excessive workload were identified among the reasons for violation of RMC.

CONCLUSION

Violation of RMC is unacceptable. Awareness of women and providers about the rights of women to respectful maternity care, training of providers on the subject, monitoring of care to prevent mistreatment, and conditioning any future technical and financial assistance to commitments to RMC is recommended.

Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review

BACKGROUND

Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.

METHODS

Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.

RESULTS

More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.

CONCLUSION

A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.

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.

Implementing midwifery services in public tertiary medical college hospitals in Bangladesh: A longitudinal study

BACKGROUND

A necessary precursor for quality maternity care provision is high quality education. The quality of care that students are exposed to during clinical education on maternity wards shapes their competencies and professional identities. In this study, we look at the introduction of midwives educated to international standards - with facility mentorship - deployed in tertiary level teaching hospitals in Bangladesh with the intention of improving the use of World Health Organization (WHO)-recommended birth practices.

AIM

To examine the outcomes of introducing midwifery services into tertiary level care facilities in Bangladesh, on the use of WHO-recommended birth practices.

METHODS

A retrospective review of patient register data was carried out to understand level of changes in use of WHO-recommended birth practices after the introduction of a midwifery service. Multivariate linear regression was applied using an interrupted time series analysis, with and without a delayed effect, to assess both level and trend change following the introduction of the midwifery service.

FINDINGS

A significant increase (p < 0.001) in use of WHO-recommended birth practices was found, both immediately following the midwives' introduction and after one year. Quality improvement was observed not only in births attended by midwives, but also in those attended by doctors and nurses.

CONCLUSION

By introducing quality maternity care provision through midwives in clinical sites, especially in tertiary-level care hospitals with large numbers of students, international standard midwives can improve the quality of clinical education in maternity wards, a critical priority for maternal health worldwide.

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

Background

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

Objective

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

Design

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

Findings

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

Conclusions and Implications for Practice

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

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

Background

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

Aim

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

Methods

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

Findings and Discussion

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

Conclusion

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

Enhancing quality midwifery care in humanitarian and fragile settings: a systematic review of interventions, support systems and enabling environments

INTRODUCTION

Women and children bear a substantial burden of the impact of conflict and instability. The number of people living in humanitarian and fragile settings (HFS) has increased significantly over the last decade. The provision of essential maternal and newborn healthcare by midwives is crucial everywhere, especially in HFS. There is limited knowledge about the interventions, support systems and enabling environments that enhance midwifery care in these settings. The aim of this paper is to identify the factors affecting an enabling environment for midwives in HFS and to explore the availability and effectiveness of support systems for midwives.

METHODS

A structured systematic review was undertaken to identify peer-reviewed primary research articles published between 1995 and 2020.

RESULTS

In total, 24 papers were included from Afghanistan, Bangladesh, Nigeria, Democratic Republic of Congo, South Sudan and Sudan, Ethiopia, Pakistan, Uganda and Liberia. There were two broad themes: (1) the facilitators of, and barriers to, an enabling environment, and (2) the importance of effective support systems for midwives. Facilitators were: community involvement and engagement and an adequate salary, incentives or benefits. Barriers included: security and safety concerns, culture and gender norms and a lack of infrastructure and supplies. Support systems were: education, professional development, supportive supervision, mentorship and workforce planning.

CONCLUSION

More efforts are needed to develop and implement quality midwifery services in HFS. There is an urgent need for more action and financing to ensure better outcomes and experiences for all women, girls and families living in these settings.

PROSPERO REGISTRATION NUMBER

CRD42021226323.

Facility-level determinants of quality routine intrapartum care in Afghanistan

BACKGROUND

Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan.

METHODS

We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores.

RESULTS

Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care.

CONCLUSIONS

Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.

Assessing respectful maternity care in a fragile, conflict-affected context: Observations from a 2016 national assessment in Afghanistan

Evidence on experiences and perceptions of care in pregnancy and childbirth in conflict-affected settings is limited. We interviewed 561 maternity care providers and observed 413 antenatal care consultations, 671 births, and 393 postnatal care consultations at public health facilities across Afghanistan. We found that healthcare providers work under stressed conditions with insufficient support, and most women receive mixed quality care. Understanding socio-cultural and contextual factors underpinning acceptance of mistreatment in childbirth, related to conflict, insecurity, gender and power dynamics, is critical for improving the quality of maternity care in Afghanistan and similar fragile and conflict affected settings.

Health workforce perspectives of barriers inhibiting the provision of quality care in Nepal and Somalia - A qualitative study

OBJECTIVE

In this paper settings from Nepal and Somalia are used to focus on the perspectives of healthcare providers within two fragile health systems. The objective of this study was to describe barriers inhibiting quality healthcare in Nepal and Somalia from a health workforce perspective.

METHODS

Data were collected through 19 semi-structured interviews with healthcare providers working in healthcare facilities. Ten interviews were conducted in Nepal and nine in Somalia.

RESULTS

Various structural barriers inhibiting the availability, accessibility, and acceptability of the quality care were similar in both countries. Barriers inhibiting the availability of quality care were linked to healthcare providers being overburdened with multiple concurrent jobs. Barriers inhibiting the accessibility to quality healthcare included long distances and the uncertain availability of transportation, and barriers to acceptability of quality healthcare was inhibited by a lack of respect from healthcare providers, characterised by neglect, verbal abuse, and lack of competence.

CONCLUSIONS

Inequality, poverty, traditional and cultural practices plus the heavy burden placed on healthcare providers are described as the underlying causes of the poor provision of quality care and the consequential shortcomings that emerge from it. In order to improve this situation adequate planning and policies that support the deployment and retention of the healthcare providers and its equitable distribution is required. Another important aspect is provision of training to equip healthcare providers with the ability to provide respectful quality care in order for the population to enjoy good standard of healthcare services.