Lessons learned through respectful maternity care training and its implementation in Ethiopia: an interventional mixed methods study

Addressing obstetric violence: a scoping review of interventions in healthcare and their impact on maternal care quality

Background

The mistreatment and abuse of women during childbirth have been recognized as a major global health challenge, impeding facility-based delivery and contributing to the high maternal mortalities globally. The World Health Organization has specifically called for interventions to deal with obstetric violence. This scoping review consolidates the existing literature on interventions aimed at reducing obstetric violence and synthesizes existing knowledge on their impact in promoting respectful maternity care.

Methodology

Thirteen electronic databases were searched for relevant articles from January 2001 to March 2023. A total of 863 records were identified, and 72 full-text articles were retrieved for further screening. The review includes 16 studies, particularly from low- and middle-income countries, with interventions implemented at medical facilities and involving both women and healthcare providers. Eight of the studies were quantitative, three were qualitative and five used a mixed-methods approach.

Findings

The results reveal a promising trend in reducing obstetric violence through various interventions. Ten different types of interventions were identified, highlighting strategies to improve the quality of maternity care and enhance patient-centered care. Improved patient-provider communication skills, increased privacy measures, and reduced abuse and mistreatment emerged as common themes. Enhanced communication skills, including open discussions and the right to be informed, were crucial in reducing obstetric violence. Privacy measures, such as separate rooms, curtains, and birth companions effectively decreased incidents of non-confidential care. General abuse and mistreatment, including physical abuse and neglect, were also reduced, leading to improved perceptions of respectful care during childbirth.

Conclusion

Overall, the interventions had a favorable impact on obstetric violence reduction and women's childbirth experiences. However, despite promising results, obstetric violence remains prevalent worldwide, necessitating more efforts to implement effective interventions. To the best of our knowledge, this is the first scoping review on obstetric violence interventions, providing a comprehensive overview of the state of the art. We suggest that further research is needed to explore new interventions, particularly gender-sensitive interventions, to contribute to a growing body of knowledge on the prevention of obstetric violence.

Challenges to the implementation of a multi-level intervention to reduce mistreatment of women during childbirth in Iran: a qualitative study using the Consolidated Framework for Implementation Research

BACKGROUND

Mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In response, we launched a comprehensive implementation research (IR) project to reduce mistreatment during childbirth and enhance positive birth experiences in birth facilities. This study identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR).

METHODS

An exploratory qualitative study, involving 30 in-depth interviews, was conducted between July 2022 and February 2023. Participants included a purposive sample of key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals) with sufficient knowledge, direct experience, and/or collaboration in the implementation of the studied interventions. Interviews were transcribed verbatim and coded using directed qualitative content analysis (CFIR constructs) in MAXQDA 18.

RESULTS

The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability, design quality and packaging, cosmopolitanism; presence of birth companions: e.g., patient needs and resources, structural characteristics, culture); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority, access to knowledge and information, reflecting and evaluating); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief during childbirth guidelines: e.g., networks and communications, patient needs and resources, executing, reflecting and evaluating).

CONCLUSIONS

This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth and highlights potential implications for policy makers and practitioners of maternal health programs. We encourage them to take the lessons learned from this study and revise their current programs and policies regarding the quality of maternity care by focusing on the identified challenges.

Implementation and evaluation of the WHO maternity care model: a convergent parallel mixed-methods study protocol

Background

According to the World Health Organization (WHO), intrapartum care is considered a platform for providing respectful, personalized, and women-centered services to women. This study aims to investigate the intrapartum care model proposed by WHO.

Methods

This convergent parallel mixed-methods study will be carried out in qualitative and quantitative phases. In the quantitative phase (a quasi-experimental study), 108 pregnant women admitted to the maternity ward will be randomized to intervention (receiving intrapartum care based on the WHO model) and control group (receiving routine hospital care) before the beginning of the active stage of labor (cervix dilatation equal to 5 cm) and Wijma's delivery fear scale (DFS) will be completed for them and again at 7-8 cm dilatation. The participants of both groups will be followed up for 6 weeks after labor and then they will be invited to a relatively quiet place to complete the Childbirth Experience Questionnaire (CEQ 2.0), the Edinburgh Postpartum Depression Scale (EPDS), the Post-Traumatic Stress Disorder (PTSD) Symptom Scale (PSS-I), the Pregnancy and Childbirth Questionnaire (PCQ), exclusive breastfeeding and a checklist on willingness to give birth to another child. The qualitative phase will employ content analysis to explain mothers' views about the effects of this model especially subjective components of this model on their labor process after 4-6 weeks. The two phase's results will be discussed in combination.

Discussion

The implementation of such care models is expected to prevent mental disorders caused by negative experiences of childbirth, and also, prevent uncontrolled increases in cesarean sections.

Clinical Trial Registration

https://fa.irct.ir/user/trial/68313/view, identifier (IRCT20120718010324N69).

Interventions to improve the quality of maternal care in Ethiopia: a scoping review

Introduction

Quality improvement interventions have been part of the national agenda aimed at reducing maternal and neonatal morbidities and mortality. Despite different interventions, neonatal mortality and morbidity rates remain steady. This review aimed to map and synthesize the evidence of maternal and newborn quality improvement interventions in Ethiopia.

Methods

A scoping review was reported based on the reporting items for systematic reviews and meta-analysis extensions for the scoping review checklist. Data extraction, collation, and organization were based on the Joanna Briggs Institute manual of the evidence synthesis framework for a scoping review. The maternal and neonatal care standards from the World Health Organization and the Donabedian quality of health framework were used to summarize the findings.

Results

Nineteen articles were included in this scoping review. The review found that the studies were conducted across various regions of Ethiopia, with the majority published after 2013. The reviewed studies mainly focused on three maternal care quality interventions: mobile and electronic health (eHealth), quality improvement standards, and human resource mobilization. Moreover, the reviewed studies explored various approaches to quality improvement, such as providing training to healthcare workers, health extension workers, traditional birth attendants, the community health development army, and mothers and supplying resources needed for maternal and newborn care.

Conclusion

In conclusion, quality improvement strategies encompass community involvement, health education, mHealth, data-driven approaches, and health system strengthening. Future research should focus on the impact of physical environment, culture, sustainability, cost-effectiveness, and long-term effects of interventions. Healthcare providers' knowledge, skills, attitudes, satisfaction, and adherence to guidelines should also be considered.

The mistreatment of women during maternity care and its association with the maternal continuum of care in health facilities

BACKGROUND

Mistreatment of childbearing women continues despite global attention to respectful care. In Ethiopia, although there have been reports of mistreatment of women during maternity care, the influence of this mistreatment on the continuum of maternity care remains unclear. In this paper, we report the prevalence of mistreatment of women from various dimensions, factors related to mistreatment and also its association to the continuum of maternity care in health facilities.

METHODS

We conducted an institution-based cross-sectional survey among women who gave birth within three months before the data collection period in Western Ethiopia. A total of 760 women participated in a survey conducted face-to-face at five health facilities during child immunization visits. Using a validated survey tool, we assessed mistreatment in four categories and employed a mixed-effects logistic regression model to identify its predictors and its association with the continuum of maternity care, presenting results as adjusted odds ratios (AORs) with their 95% confidence intervals (CIs).

RESULTS

Over a third of women (37.4%) experienced interpersonal abuse, 29.9% received substandard care, 50.9% had poor interactions with healthcare providers, and 6.2% faced health system constraints. The odds of mistreatment were higher among women from the lowest economic status, gave birth vaginally and those who encountered complications during pregnancy or birth, while having a companion of choice during maternity care was associated to reduced odds of mistreatment by 42% (AOR = 0.58, 95% CI: [0.42-0.81]). Women who experienced physical abuse, verbal abuse, stigma, or discrimination during maternity care had a significantly reduced likelihood of completing the continuum of care, with their odds decreased by half compared to those who did not face such interpersonal abuse (AOR = 0.49, 95% CI: [0.29-0.83]).

CONCLUSIONS

Mistreatment of women was found to be a pervasive problem that extends beyond labour and birth, it negatively affects upon maternal continuum of care. Addressing this issue requires an effort to prevent mistreatment through attitude and value transformation trainings. Such interventions should align with a system level actions, including enforcing respectful care as a competency, enhancing health centre functionality, improving the referral system, and influencing communities to demand respectful care.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Improving respectful maternity care through group antenatal care: findings from a cluster randomized controlled trial

Background

Disrespect and patient mistreatment are identified as barriers to care-seeking and low uptake of facility-based deliveries. These mitigating factors have led to slow progress in the achievement of maternal and child health targets, especially in Ghana. Group antenatal care, as an alternative to individual antenatal was implemented to explore the impact on outcomes, including mothers' perception of respectful care.

Methods

A cluster randomized controlled trial was conducted in 14 health facilities across four districts in the Easter Region of Ghana. These facilities were randomized to intervention or control using a matched pair. Data was collected at several timepoints: enrollment (Time 0), 34 weeks gestation to 3 weeks post-delivery (Time 1), 6 to 12 weeks post-delivery (Time 2), 5 to 8 months post-delivery (Time 3), and 11 to 14 months post-delivery (Time 4). Questions related to respectful care were asked at Time 2, while a focus group discussion (FGDs) was conducted as part of a process evaluation to examine participants' experiences about respectful maternity care.

Results

The findings from the intervention group indicate that participants perceived higher levels of respect in comparison to the control group. Privacy and con dentiality were maintained. They believed they had been provided with adequate information, education, and counseling, empowering them to make informed decisions. Participants perceived a shortened waiting time and reduced discrimination in care provision. Generally, there were higher levels of satisfaction with antenatal care.

Conclusion

The provision of respectful maternity care, which is essential to increasing healthcare utilization, has been demonstrated to correlate positively with group antenatal care.

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.

Community perspectives and experiences of quality maternal and newborn care in East New Britain, Papua New Guinea

BACKGROUND

Quality maternal and newborn care is essential for improving the health of mothers and babies. Low- and middle-income countries, such as Papua New Guinea (PNG), face many barriers to achieving quality care for all. Efforts to improve the quality of maternal and newborn care must involve community in the design, implementation, and evaluation of initiatives to ensure that interventions are appropriate and relevant for the target community. We aimed to describe community members' perspectives and experiences of maternal and newborn care, and their ideas for improvement in one province, East New Britain, in PNG.

METHODS

We undertook a qualitative descriptive study in partnership with and alongside five local health facilities, health care workers and community members, using a Partnership Defined Quality Approach. We conducted ten focus group discussions with 68 community members (identified through church, market and other community-based groups) in East New Britain PNG to explore perspectives and experiences of maternal and newborn care, identify enablers and barriers to quality care and interventions to improve care. Discussions were transcribed verbatim. A mixed inductive and deductive analysis was conducted including application of the World Health Organisation (WHO) Quality Maternal and Newborn Care framework.

RESULTS

Using the WHO framework, we present the findings in accordance with the five experience of care domains. We found that the community reported multiple challenges in accessing care and facilities were described as under-staffed and under resourced. Community members emphasised the importance of good communication and competent, caring and respectful healthcare workers. Both women and men expressed a strong desire for companionship during labor and birth. Several changes were suggested by the community that could immediately improve the quality of care.

CONCLUSIONS

Community perspectives and experiences are critical for informing effective and sustainable interventions to improve the quality of maternal and newborn care and increasing facility-based births in PNG. A greater understanding of the care experience as a key component of quality care is needed and any quality improvement initiatives must include the user experience as a key outcome measure.

The roles of multi-component interventions in reducing mistreatment of women and enhancing respectful maternity care: a systematic review

BACKGROUND

Despite recognition of the adverse impacts of the mistreatment of women during pregnancy, labour and birth, there remains limited evidence on interventions that could reduce mistreatment and build a culture of respectful maternity care (RMC) in health facilities. The sustainability of effective individual interventions and their adaptability to various global contexts remain uncertain. In this systematic review, we aimed to synthesise the best available evidence that has been shown to be effective in reducing the mistreatment of women and/or enhancing RMC during women's maternity care in health facilities.

METHODS

We searched the online databases PubMed, CINAHL, EBSCO Nursing/Academic Edition, Embase, African Journals Online (AJOL), Scopus, Web of Science, and grey literature using predetermined search strategies. We included cluster randomized controlled trials (RCTs) and pre-and-post observational studies and appraised them using JBI critical appraisal checklists. The findings were synthesised narratively without conducting a meta-analysis. The certainty of evidence was assessed using GRADE criteria.

RESULTS

From the 1493 identified records, 11 studies from six sub-Sahara African countries and one study from India were included: three cluster RCTs and nine pre- and post-studies. We identified diverse interventions implemented via various approaches including individual health care providers, health systems, and policy amendments. Moderate certainty evidence from two cluster RCTs and four pre- and post-studies suggests that multi-component interventions can reduce the odds of mistreatment that women may experience in health facilities, with odds of reduction ranging from 18 per cent to 66 per cent. Similarly, women's perceptions of maternity care as respectful increased in moderate certainty evidence from two cluster RCTs and five pre- and post-studies with reported increases ranging from 5 per cent to 50 per cent.

CONCLUSIONS

Multi-component interventions that address attitudes and behaviors of health care providers, motivate staff, engage the local community, and alleviate health facility and system constraints have been found to effectively reduce mistreatment of women and/or increase respectful maternity care. Such interventions which go beyond a single focus like staff training appear to be more likely to bring about change. Therefore, future interventions should consider diverse approaches that incorporate these components to improve maternal care.

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.

Disrespect and abuse in maternity care in a low-resource setting in Tanzania: Provider's perspectives of practice

BACKGROUND

Globally, women experience disrespectful and abusive care from maternity healthcare providers at health facilities, committed intentionally or unintentionally, particularly during labor and delivery. Disrespectful care affects women's childbirth experience and birth outcomes.

METHODS

This study used a descriptive qualitative design to obtain thick and rich data on disrespect and abuse in maternity care in a low-resource setting in Tanzania. Three days workshop was conducted at the Aga Khan University comprising maternity healthcare providers from diverse settings. The workshop was designed based on the existing evidence and anecdotal data and inspired by the authors' experiences of disrespectful and abusive care (stereotyping clients, not listening to client's/relatives' concerns, unconsented care) as a client, relative, or observant of colleagues. The targeted audience was maternity healthcare providers from public and private health facilities in the Dar es Salaam region. Data collection encompassed individual responses (reflection of practice) obtained by individuals, anonymously written reflections of practice, and compiled notes from group discussions. Data were analysed thematically guided by six steps described by Braun and Clerk.

RESULTS

A total of 80 maternity healthcare providers participated in the workshop from various health facilities, including dispensaries (n = 25), health centres (n = 2), and hospitals (n = 3) located in semi-urban Dar es Salaam. Four main themes were identified from the data: Physical and verbal abuse; Lack of professional ethics and integrity; Vulnerable working environment; Abuse and disrespect to care providers. In addition, several sub-themes were identified within these themes: Harsh and abusive language; Beating/slapping/pinching of the mother in labor; notably, Junior midwives also disrespected and abused women; Lack of privacy and confidentiality; Poor communication; No consent for maternity healthcare procedures; Lack of courtesy and poor interpersonal skills; and, negligence of care and woman's needs.

CONCLUSION

The actions of disrespect and abuse are alarming in practice and are associated with ignorance of fundamental human rights by both providers and recipients of services. Conducting workshops seems a useful approach to revealing disrespect and abuse deep-rooted in practice and provides an opportunity to rectify the problem with providers. A more extensive interventional study will be crucial to address the widespread actions of disrespect and abuse.

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.

Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff

INTRODUCTION

Respectful maternity care (RMC) during childbirth is an integral component of quality of care. However, women's experiences of mistreatment are prevalent in many low- and middle-income countries. This is a complex phenomenon that has not been well explored from a behavioral science perspective. We aimed to understand the behavioral drivers of mistreatment during childbirth among maternity care staff at public health facilities in the Sindh province of Pakistan.

METHODS

Applying the COM-B (capability-opportunity-motivation that leads to behavior change) model, we conducted semistructured in-depth interviews among clinical and nonclinical staff in public health facilities in Thatta and Sujawal, Sindh, Pakistan. Data were analyzed using thematic deductive analysis, and findings were synthesized using the COM-B model.

RESULTS

We identified several behavioral drivers of mistreatment during childbirth: (1) institutional guidelines on RMC and training opportunities were absent, resulting in a lack of providers' knowledge and skills; (2) facilities lacked the infrastructure to maintain patient privacy and confidentiality and did not permit males as birth companions; (3) lack of provider performance monitoring system and patient feedback mechanism contributed to providers not feeling appreciated or recognized. Staff bias against patients from lower castes contributed to patient abuse and mistreatment. The perspectives of clinical and nonclinical staff overlapped regarding potential drivers of mistreatment during childbirth.

CONCLUSIONS

Addressing mistreatment during childbirth requires improving the knowledge and capacity of maternity staff on RMC and psychosocial support to enhance their understanding of RMC. At the health facility level, governance and accountability mechanisms in routine supervision and monitoring of staff need to be improved. Patients' feedback should be incorporated for continuous improvement in providing maternity care services that meet patients' preferences and needs.

Upskilling nursing students in Nepal: Evaluation of an online education module for promoting respectful maternity care

OBJECTIVE

To explore Nepalese nursing student...s evaluation of an online education module on respectful maternity care.

DESIGN

Cross-sectional study.

SETTING

A medical college in Chitwan, Nepal.

PARTICIPANTS

Forty third-year undergraduate nursing students.

METHODS

Over a three-week time frame, students undertook three, two-hour online education sessions about respectful maternity care. Students were then invited to complete a purposely designed evaluation survey with 13 Likert-scale and yes/no items, and eight open-ended questions about the quality, relevance, impact, and areas for improvement of the education module. Responses were analysed using descriptive statistics and qualitative thematic analysis.

FINDINGS

Students considered the education module to be useful and informative about respectful maternity care. More than half (60%) of the students agreed that the online delivery was more convenient than face-to-face, and learning was equivalent to a traditional class (87.5%). Most students (92.5%) reported that respectful maternity care is not explicitly covered in their degree. Students recommended that respectful maternity care be included in the curriculum and similar education offered to staff and women. Three themes from open-ended questions revealed: 1) empowerment through respectful maternity care; 2) motivation to initiate change; and 3) becoming a respectful clinician.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Respect is essential in all areas of maternity care for improved experiences and outcomes for women and babies. Participants considered that the brief intervention improved their understanding of respectful maternity care and were inspired to implement change in their own practice to be more respectful to women. Curricula in all Nepalese institutions that offer preregistration education should customarily include respectful maternity care. Further research about respectful maternity care from the standpoint of women, educators, students, and maternity care providers in Nepal is required.

A qualitative enquiry of health care workers' narratives on knowledge and sources of information on principles of Respectful Maternity Care (RMC)

Research from sub-Saharan Africa indicate that many women experience varied forms of disrespectful maternity care, which amount to a violation of their rights and dignity. Notably, there is little research that sheds light on health care workers (HCWs) training and knowledge of principles of respectful maternity care (RMC). Formulating appropriate interventional strategies to promote the respectful provision of services for women during pregnancy, childbirth, and postpartum period requires an understanding of the current state of knowledge and sources of information on respectful maternity care among HCWs. This paper reports findings from a qualitative study that examined the knowledge and sources of information on the Respectful Maternity Care Charter among HCWs in rural Kisii and Kilifi counties in Kenya. Between January and March 2020, we conducted 24 in-depth interviews among HCWs in rural Kisii and Kilifi health facilities. Data were analyzed using a mixed deductive and inductive thematic analysis guided by Braun's [2006] six stages of analysis. We found that from the seven globally accepted principles of respectful maternity care, at least half of the HCWs were aware of patients right to consented care, confidentiality and privacy, and the right to non-discriminatory care based on specific attributes. Knowledge of the right to no physical and emotional abuse, abandonment of care, and detentions in the facilities was limited to a minority of health care workers but only after prompting. Sources of information on respectful maternity care were largely limited to continuous medical and professional training and clinical mentorship. The existing gap shows the need for training and mentorship of HCWs on the Respectful Maternity Care Charter as part of pre-service medical and nursing curricula and continuing clinical education to bridge this gap. At the policy level, strategies are necessary to support the integration of respectful maternity care into pre-service training curricula.

Women’s perspectives on disrespect and abuse experiences during childbirth in a teaching hospital in Southwest Ethiopia: a qualitative study

There is evidence that women in Ethiopia often face disrespect and abuse in health care facilities during childbirth. Disrespect and abuse (D&A) violate women’s right to dignified, respectful health care and decrease their trust in health care facilities. There is a need for more insight into women’s perspectives on D&A during childbirth in different contexts. Therefore, this study aimed to explore women’s perspectives on D&A during childbirth in a teaching hospital in South-West Ethiopia. A qualitative study was conducted from November 2017 to February 2018 using in-depth interviews and focus group discussions. Postnatal women were purposively chosen and scheduled for interviews six weeks postpartum. Data saturation occurred once 32 women were interviewed, and four focus group discussions were conducted. A thematic analysis method was used to analyse the data using MAXQDA qualitative analysis software. Three main themes emerged from the data: disrespect and abuse, its contributors, and perceived consequences. The subthemes of D&A include neglected care, non-consented care, physical abuse, lack of privacy, loss of autonomy, objectification, lack of companionship, and verbal abuse. The subthemes of contributors include health care provider-related, health care system-related, and women-related contributors. The subthemes of perceived consequences include the fear of using health care facilities. Women in Ethiopia experienced D&A. Health system factors, such as the teaching environment and scarcity of supplies, contribute the most to the identified D&A. Therefore, providers, administrators, training institutions, and researchers must collaborate to address these health system factors to reduce disrespect and abuse during childbirth in teaching hospitals.

Disrespect and abuse experienced by women giving birth in public health facilities of Eastern Ethiopia: a multicenter cross-sectional study

OBJECTIVE

We assessed the magnitude of disrespect and abuse experienced by women giving birth at public health facilities in Dire Dawa, Eastern Ethiopia.

METHODS

We conducted a facility-based quantitative cross-sectional study in Dire Dawa City Administration from 21 October to 8 December 2020. We used a pre-tested structured questionnaire to interview 555 randomly selected women who gave birth in public health facilities during the study period. Bivariate and multivariate logistic regression analysis was performed in statistical analysis.

RESULTS

Among 555 women, 473 (85.2%) reported having experienced at least one form of disrespect and abuse. Giving birth at a hospital (adjusted odds ratio [AOR] = 4.15; 95% confidence interval [CI], 2.29-7.51) and being attended by male providers (AOR = 3.27; 95% CI, 1.57-6.81), as well as being attended by three or four providers (AOR = 0.44; 95% CI, 0.22-0.88) and delivering at night (AOR = 0.27; 95% CI, 0.15-0.48) were significantly associated with greater or less likelihood, respectively, of disrespect and abuse.

CONCLUSION

We revealed an unacceptable level of disrespect and abuse toward women giving birth at public health facilities. Health care providers must understand the importance of respectful maternity care. The city's health bureau should conduct provider training and enforce adherence to respectful care.

A landscaping review of interventions to promote respectful maternal care in Africa: Opportunities to advance innovation and accountability

OBJECTIVE

In the past decade, global recognition of the need to address disrespect and abuse (also described as mistreatment of women) and promote respectful maternal care in facility-based childbirth has increased. While many studies have documented gaps in respectful maternal care, little is known about the design and implementation of these interventions. Our aim was to summarize and describe respectful maternal care -promoting interventions during childbirth implemented in Africa.

DESIGN

We identified respectful maternal care -promoting interventions in Africa through a rapid scoping of peer-reviewed articles and gray literature, and a crowdsourcing survey distributed through stakeholder networks.

SETTING

Africa PARTICIPANTS: NA MEASUREMENTS AND FINDINGS: We identified 43 unique interventions implemented in 16 African countries, gathered from a crowdsourcing survey, gray and published literature between 2010 and 2020. Most interventions were implemented in East Africa (N = 13). The interventions had various targets and were categorized into nine approaches, 60% of interventions focused on training providers about respectful maternal care and practice. About two thirds included multiple intervention approaches, and about two thirds addressed respectful maternal care beyond the period of childbirth. Few publications presented data on the effectiveness of the intervention, and those that did used a wide variety of indicators.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a reliance on provider training approaches to promote respectful maternal care and there are few examples of either engaging women in the community or adopting social accountability approaches. We encourage implementors to develop interventions targeting multiple approaches beyond provider training and consider delivery across pre-pregnancy, pregnancy, birth, and the postnatal periods. Finally, in order to effectively move from documenting respectful maternal care gaps to action and scale, we need global consensus on common indicators and measures of effectiveness for interventions promoting respectful care across the life course.

Effectiveness of an online education intervention to enhance student perceptions of Respectful Maternity Care: A quasi-experimental study

BACKGROUND

Childbearing women's relationship with maternity care providers enhance childbirth outcomes. Students need to understand and offer respectful care.

OBJECTIVE

Evaluate effectiveness and impact of an online education intervention on nursing students' perceptions towards respectful maternity care during labour and childbirth in Nepal.

DESIGN

A quasi-experimental pre-post design was used.

PARTICIPANTS

A total of 89 Third Year Bachelor of Nursing students (intervention n = 40; control n = 49) from three participating colleges.

METHODS

Students completed online pre and post-test surveys using the Students' Perceptions of Respectful Maternity Care scale and questions about impact of the intervention. The intervention group received six hours of education delivered online (three sessions x three weeks). ANCOVA and non-parametric Wilcoxon signed-rank tests measured effects.

RESULTS

Compared to controls, students in the intervention group reported a significant increase in perceptions towards respectful maternity care (F (1, 86) = 28.19, p < 0.001, η_p² = 0.25). Participants reported a good understanding of respectful maternity care (75%), positive views about providing such care (82.5%), and a desire to use their new knowledge in practice (65%).

CONCLUSION

Relatively few intervention studies to promote respectful maternity care in students have been published. This brief online intervention improved students' perceptions. The intervention package can be integrated into nursing or midwifery curricula and in-service training. A larger study with longer follow-up is needed to support current findings.

Partnership-defined quality approach to companionship during labour and birth in East New Britain, Papua New Guinea: A mixed-methods study

Companionship during labour and birth is a critical component of quality maternal and newborn care, resulting in improved care experiences and better birth outcomes. Little is known about the preferences and experiences of companionship in Papua New Guinea (PNG), and how it can be implemented in a culturally appropriate way. The aim of this study was to describe perspectives and experiences of women, their partners and health providers regarding labour and birth companionship, identify enablers and barriers and develop a framework for implementing this intervention in PNG health facilities. A mixed methods study was conducted with five facilities in East New Britain, PNG. Data included 5 facility audits, 30 labour observations and 29 in-depth interviews with women who had recently given birth, partners and maternity care providers. A conceptual framework was developed drawing on existing quality care implementation frameworks. Women and partners wanted companions to be present, whilst health providers had mixed views. Participants described benefits of companionship including encouragement and physical support for women, better communication and advocacy, improved labour outcomes and assistance with workforce issues. Adequate privacy and space constraints were highlighted as key barriers to address. Of the women observed, only 30% of women had a companion present during labour, and 10% had a companion at birth. A conceptual framework was used to highlight the interconnected inputs required at community, facility and provincial health system levels to improve the quality of care. Key elements to address included attitudes towards companionship, the need for education and training and restrictive hospital policies. Supporting women to have their companion of choice present during labour and birth is critical to improving women's experiences of care and improving the quality of maternal and newborn care. In order to provide companionship during labour and birth in PNG, a complex, intersecting, multi-faceted approach is required.

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.

Midwives' perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study

Background

Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers’ perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria.

Materials and methods

This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically.

Results

The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives’ perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives’ weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care.

Conclusion

PCMC is inadequate in public hospitals as seen from midwives’ perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives’ delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.

Adherence to respectful maternity care guidelines during COVID-19 pandemic and associated factors among healthcare providers working at hospitals in northwest Ethiopia: A multicenter, observational study

Background

Respectful maternity care is one of the facilitators of women's access to maternity healthcare services. However, it has been evidenced that maternal healthcare services are compromised during the pandemic of coronavirus disease 19 (COVID-19). Moreover, there was a dearth of evidence on healthcare provider's adherence to respectful maternity care guidelines through direct observation. Hence, this study intended to assess healthcare provider's adherence to respectful maternity care guidelines during COVID-19 in northwest Ethiopia.

Methods

A multicenter observational cross-sectional study was conducted at hospitals in northwest Ethiopia from November 15th/2020 to March 10th/2021. A simple random sampling technique was employed to select 406 healthcare providers. Data were collected through face-to-face interviews and direct observation using a structured questionnaire and standardized checklist respectively. The data were entered into Epi Info 7.1.2 and exported to SPSS version 25 for analysis. A binary logistic regression model was fitted. Both bivariable and multivariable logistic regression analyses were undertaken. The level of significance was claimed based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) at a p-value of ≤0.05.

Results

The proportion of healthcare providers adhering to respectful maternity care guidelines during COVID-19 was 63.8% (95% CI: 59.1, 68.4). Job satisfaction (AOR = 1.82; 95% CI: 1.04, 3.18), professional work experience of 3–5 years (AOR = 2.84; 95% CI: 1.74, 4.6) and ≥6 years (AOR = 2.21; 95% CI: 1.11, 4.38), and having education parallel to work (AOR = 0.33; 95% CI: 0.21, 0.51) have an independent statistical significant association with adherence to respectful maternity care guidelines.

Conclusion

In this study, six out of ten healthcare providers had good adherence to respectful maternity care guidelines. Ensuring health worker's job satisfaction and providing education opportunities by the government would improve healthcare provider's adherence to respectful maternity care standards.

Presence of birth companion-a deterrent to disrespectful behaviours towards women during delivery: an exploratory mixed-method study in 18 public hospitals of India

Birthing women require support, particularly emotional support, during the process of labour and delivery. Traditionally, across cultures, this support was made available by the continuous presence of a companion during labour, childbirth and the immediate post-partum period. However, this practice is not universal, especially in health facilities in low- and middle-income countries. This cross-sectional study was conducted in 18 tertiary health care facilities of India using a mixed-method approach. The quantitative data were collected to document the number of birthing women, birth companions and healthcare providers in the labour rooms, and the typology of disrespect and abuse (D&A) faced by women. This was followed by in-depth interviews with 55 providers to understand their perspective on the various dimensions of D&A and the challenges they face to provide respectful care. This article explores the status of birth companionship in India and its plausible associations with D&A faced by birthing women in public facilities. Our study reveals that birth companionship is still not a common practice in Indian public hospitals. Birth companions were present during less than half of the observational period, also less than half of the birthing women were accompanied by a birth companion. Lack of hospital policy, space constraints, overcrowding and privacy concerns for other patients were cited as reasons for not allowing birth companions in the labour rooms, whose supportive roles, both for women and providers, were otherwise widely acknowledged during the qualitative interviews. Also, the presence of birth companions was found to be critically negatively associated with occurrences of D&A of birthing women. We contend that owing to the high pressure on the public hospitals in India, birth companions can be a low-cost intervention model for promoting respectful maternity care. However, adequate infrastructure is a critical aspect to be taken care of.

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

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

Mitigating the mistreatment of childbearing women: evaluation of respectful maternity care intervention in Ethiopian hospitals

OBJECTIVES

There is a lack of evidence on approaches to mitigating mistreatment during facility-based childbirth. This study compares the experiences of mistreatment reported by childbearing women before and after implementation of a respectful maternity care intervention.

DESIGN

A pre-post study design was undertaken to quantify changes in women's experiences of mistreatment during facility-based childbirth before and after the respectful maternity care intervention.

INTERVENTION

A respectful maternity care intervention was implemented in three hospitals in southern Ethiopia between December 2017 and September 2018 and it included training of service providers, placement of wall posters in labour rooms and post-training supportive visits for quality improvement.

OUTCOME MEASURES

A 25-item questionnaire asking women about mistreatment experiences was administered to 388 women (198 in the pre-intervention, 190 in the post-intervention). The outcome variable was the number of mistreatment components experienced by women, expressed as a score out of 25. Multilevel mixed-effects Poisson modelling was used to assess the change in mistreatment score from pre-intervention to post-intervention periods.

RESULTS

The number of mistreatment components experienced by women was reduced by 18% when the post-intervention group was compared with the pre-intervention group (adjusted regression coefficient (Aβ)=0.82, 95% CI 0.74 to 0.91). Women who had a complication during pregnancy (Aβ=1.17, 95% CI 1.01 to 1.34) and childbirth (Aβ=1.16, 95% CI 1.03 to 1.32) experienced a greater number of mistreatment components. On the other hand, women who gave birth by caesarean birth after trial of vaginal birth (Aβ=0.76, 95% CI 0.63 to 0.92) and caesarean birth without trial of vaginal birth (Aβ=0.68, 95% CI 0.47 to 0.98) experienced a lesser number of mistreatment components compared with those who had vaginal birth.

CONCLUSIONS

Women reported significantly fewer mistreatment experiences during childbirth following implementation of the intervention. Given the variety of factors that lead to mistreatment in health facilities, interventions designed to mitigate mistreatment need to involve structural changes.