A qualitative study on acceptability of the mistreatment of women during childbirth in Myanmar

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.

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.

Factors influencing maternal death in Cambodia, Laos, Myanmar, and Vietnam countries: A systematic review

BACKGROUND

A maternal mortality ratio is a sensitive indicator when comparing the overall maternal health between countries and its very high figure indicates the failure of maternal healthcare efforts. Cambodia, Laos, Myanmar, and Vietnam-CLMV countries are the low-income countries of the South-East Asia region where their maternal mortality ratios are disproportionately high. This systematic review aimed to summarize all possible factors influencing maternal mortality in CLMV countries.

METHODS

This systematic review applied "The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist (2020)", Three key phrases: "Maternal Mortality and Health Outcome", "Maternal Healthcare Interventions" and "CLMV Countries" were used for the literature search. 75 full-text papers were systematically selected from three databases (PubMed, Google Scholar and Hinari). Two stages of data analysis were descriptive analysis of the general information of the included papers and qualitative analysis of key findings.

RESULTS

Poor family income, illiteracy, low education levels, living in poor households, and agricultural and unskilled manual job types of mothers contributed to insufficient antenatal care. Maternal factors like non-marital status and sex-associated work were highly associated with induced abortions while being rural women, ethnic minorities, poor maternal knowledge and attitudes, certain social and cultural beliefs and husbands' influences directly contributed to the limitations of maternal healthcare services. Maternal factors that made more contributions to poor maternal healthcare outcomes included lower quintiles of wealth index, maternal smoking and drinking behaviours, early and elderly age at marriage, over 35 years pregnancies, unfavourable birth history, gender-based violence experiences, multigravida and higher parity. Higher unmet needs and lower demands for maternal healthcare services occurred among women living far from healthcare facilities. Regarding the maternal healthcare workforce, the quality and number of healthcare providers, the development of healthcare infrastructures and human resource management policy appeared to be arguable. Concerning maternal healthcare service use, the provisions of mobile and outreach maternal healthcare services were inconvenient and limited.

CONCLUSION

Low utilization rates were due to several supply-side constraints. The results will advance knowledge about maternal healthcare and mortality and provide a valuable summary to policymakers for developing policies and strategies promoting high-quality maternal healthcare.

Towards a better tomorrow: addressing intersectional gender power relations to eradicate inequities in maternal health

An equity lens to maternal health has typically focused on assessing the differences in coverage and use of healthcare services and critical interventions. While this approach is important, we argue that healthcare experiences, dignity, rights, justice, and well-being are fundamental components of high quality and person-centred maternal healthcare that must also be considered. Looking at differences across one dimension alone does not reflect how fundamental drivers of maternal health inequities-including racism, ethnic or caste-based discrimination, and gendered power relations-operate. In this paper, we describe how using an intersectionality approach to maternal health can illuminate how power and privilege (and conversely oppression and exclusion) intersect and drive inequities. We present an intersectionality-informed analysis on antenatal care quality to illustrate the advantages of this approach, and what is lost in its absence. We reviewed and mapped equity-informed interventions in maternal health to existing literature to identify opportunities for improvement and areas for innovation. The gaps and opportunities identified were then synthesised to propose recommendations on how to apply an intersectionality lens to maternal health research, programmes, and policies.

Perspectives of women on availing antenatal services in urban poor areas of Rishikesh, Uttarakhand

Background Antenatal care (ANC) is the essential regular care of women that prevents potential health problems during pregnancy. In India, the proportion of women who received four or more antenatal visits was only 51% (National Family Health Survey, 2015-2016). An even worse situation prevails in urban areas where women from poor communities face greater health risks. We assessed various barriers women residing in these areas come across in availing ANC services. Methods This study is a part of a mixed-methods, community-based study, and we report its qualitative component. We conducted the study at the residence of the study participants in September-October 2019. The study participants were women who had less than four antenatal visits throughout the pregnancy. Twelve in-depth interviews were conducted based on data saturation. Data were transcribed and themes were drawn concerning the gender analysis framework. Results Through this study, we found how gender relations affect the utilization of antenatal services concerning access to resources, division of labour, social norms including the belief of husband and other family members towards pregnancy and decision-making power of women. Conclusion Our findings underline the importance of making the urban health system gender-sensitive and responsive to the needs of women during pregnancy. There is a need to educate men regarding maternal health so as to allay such social norms that label pregnancy as a woman's responsibility and encouraging them to accompany their wives during pregnancy visits, thus making men a part of antenatal services.

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.

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.

A tool to define and measure maternal healthcare acceptability at a selected health sub-district in South Africa

BACKGROUND

There are many factors during pregnancy and labor that influence women's acceptability of maternal healthcare. Nevertheless, the concept of acceptability of maternal healthcare has unfortunately not been clearly defined and remains difficult to assess, affecting its implications and approaches from maternal health perspectives. In this study, we proposed a practical definition of maternal healthcare acceptability and developed a tool to measure maternal healthcare acceptability from patients' perspective at a selected health sub-district in South Africa.

METHODS

We applied known techniques to develop measurement tools in health settings. The concept development drew from the literature review leading to the proposed definition of maternal healthcare acceptability which was then refined and validated by experts through Delphi technique. Other techniques included specification of concept constructs; selection of indicators; formation of indices; measurement tool/scale construction; and testing of reliability and validity. Factor analysis and simple arithmetic equation were performed on secondary and primary datasets respectively.

RESULTS

Experts in the field reached a consensual definition of maternal healthcare acceptability. Factor analysis revealed three factors retained to predict maternal healthcare acceptability indices, namely provider, healthcare and community. Structural equation model showed good fit (CFI = 0.97), with good reliability and validity. Hypothesis testing confirmed that items and their corresponding factors were related (p < 0.01). Simple arithmetic equation was recommended as alternative method to measure acceptability when factor analysis was not applicable.

CONCLUSION

This study provides new insights into defining and measuring acceptability of maternal healthcare with significant contributions on existing theories and practices on this topic and practical applications not only for maternal health but also across diverse health disciplines.

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.

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.

Professional learning using storytelling videos of childbirth experiences: A qualitative pilot study of student midwives' perceptions in Myanmar

AIMS

To explore and describe Myanmar student midwives' perceptions of professional learning using storytelling videos of women's childbirth experiences by conducting a qualitative study and to assess potential pedagogical uses of storytelling videos in midwifery education.

METHODS

This pilot study used a qualitative content analysis study design implemented as part of the Diversity and commonalities of birth from women's voice sharing project of the Toyota Foundation. Storytelling videos of the childbirth experiences of seven Asian women (three Myanmar, three Lao, and one Japanese women) were viewed by the students. Thereafter, a semistructured interview with focus group discussion was conducted to explore and assess the students' perceptions.

SETTING

Kyaing Tong township, Shan State, Myanmar.

PARTICIPANTS

Five second-year midwifery students from a single midwifery training school in Myanmar.

RESULTS

Data analysis of their perceptions yielded four major categories: (1) deep reverence for women/mothers;; (2) respectful attitude as a midwife to support mothers; (3) wish for a safe and secure birth environment; and (4) importance of learning from the mother's voice.

CONCLUSIONS

The student midwives realized the importance of listening to the mothers' voices regardless of the nationalities or cultural background. The findings indicated that the storytelling videos broadened the students' perspectives of pregnancy and childbirth, and motivated them to provide better maternity care. Storytelling videos of childbirth experiences can be powerful educational materials for enhancing professional learning of student midwives.

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.

Development of measures for assessing mistreatment of women during facility-based childbirth based on labour observations

INTRODUCTION

Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings.

METHODS

Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO's multicountry study 'How women are treated during facility-based childbirth' (2016-2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability.

RESULTS

Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index and a 12-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries based on factor loadings and interitem correlations, indicating good structural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.60 in Ghana and Guinea. Low correlations (Spearman correlation range: -0.06-0.19; p≥0.05) between mistreatment measures supported our decision to develop three separate measures. Predictive criterion validation yielded mixed results across countries. Both items within measures and measure scores were internally consistent across countries; each item co-occurred with other items in a measure, and scores consistently distinguished between 'high' and 'low' mistreatment levels.

CONCLUSION

The set of concise, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify burden, identify risk factors and determine its impact on health and well-being outcomes. Further validation and reliability testing of the measures in other contexts is needed.

A scoping review protocol: Mapping the range of policy-related evidence influencing maternal health outcomes in a fragile, low-income country

AIM

The aim of this scoping review is to map the range of policy-related evidence influencing maternal health outcomes and determine the cultural and contextual factors influencing maternal health in Myanmar, a low-income, fragile setting.

DESIGN

Eligible studies identified will include maternal health-related policies, policy documents and research. All types of health-related policies aimed at targeting population health and well-being influencing maternal mortality and morbidity will be considered.

METHODS

This scoping review has been developed using the Joanna Briggs Institute recommendations. The database search will include MEDLINE, CINAHL, Web of Science, Cochrane Library and the grey literature. Documents published in English and Burmese in the past 10 years will be included. Numerical data will be extracted and summarized in diagrammatic form, and a descriptive format will be used to present narrative accounts. Funding approval was granted by the Economic and Social Research Council in January 2020. This protocol was registered with OSF registries (Open-ended Registration) on 30 March 2021.

DISCUSSION

Little is known about which strategies work best as there is less evidence related to health policy and contextual factors in which maternal health care is delivered in fragile, low-income settings. Understanding the context of maternal health is key to the planning and implementation of effective maternal health services designed to address women's needs.

IMPACT

This review will map the range of policy-related evidence influencing maternal health outcomes in Myanmar and will underpin future large-scale research in other low-income and fragile settings. The results of this scoping review will provide recommendations for developing and improving practice and education for nurses and midwives working in resource-restricted contexts.

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.

Correlation among experience of person-centered maternity care, provision of care and women's satisfaction: Cross sectional study in Colombo, Sri Lanka

Person-centered maternity care (PCMC) is defined as care which is respectful of and responsive to women's and families' preferences, needs, and values. In this cross-sectional study we aimed to evaluate the correlations among the degree of PCMC implementation, key indicators of provision of care, and women's satisfaction with maternity care in Sri Lanka. Degree of PCMC implementation was assessed using a validated questionnaire. Provision of good key practices was measured with the World Health Organization (WHO) Bologna Score, whose items include: 1) companionship in childbirth; 2) use of partogram; 3) absence of labor stimulation; 4) childbirth in non-supine position; 5) skin-to-skin contact. Women's overall satisfaction was assessed on a 1-10 Likert scale. Among 400 women giving birth vaginally, 207 (51.8%) had at least one clinical risk factor and 52 (13.0%) at least one complication. The PCMC implementation mean score was 42.3 (95%CI 41.3-43.4), out of a maximum score of 90. Overall, while 367 (91.8%) women were monitored with a partogram, and 293 (73.3%) delivered non-supine, only 19 (4.8%) did not receive labour stimulation, only 38 (9.5%) had a companion at childbirth, and 165 (41.3%) had skin-to-skin contact immediately after birth. The median total satisfaction score was 7 (IQR 5-9). PCMC implementation had a moderate correlation with women's satisfaction (r = 0.58), while Bologna score had a very low correlation both with satisfaction (r = 0.12), and PCMC (r = 0.20). Factors significantly associated with higher PCMC score were number of pregnancies (p = 0.015), ethnicity (p<0.001), presence of a companion at childbirth (p = 0.037); absence of labor stimulation (p = 0.019); delivery in non-supine position (p = 0.016); and skin-to-skin contact (p = 0.005). Study findings indicate evidence of poor-quality care across several domains of mistreatment in childbirth in Sri Lanka. In addition, patient satisfaction as an indicator of quality care is inadequate to inform health systems reform.

Women's experiences of mistreatment during childbirth and their satisfaction with care: findings from a multicountry community-based study in four countries

INTRODUCTION

Experiences of care and satisfaction are intrinsically linked, as user's experiences of care may directly impact satisfaction, or indirectly impact user's expectations and values. Both experiences of care and satisfaction are important to measure so that quality can be monitored and improved. Globally, women experience mistreatment during childbirth at facilities; however, there is limited evidence exploring the mistreatment and women's satisfaction with care during childbirth.

METHODS

This is a secondary analysis of a cross-sectional survey within the WHO study 'How women are treated during facility-based childbirth' exploring the mistreatment of women during childbirth in Ghana, Guinea, Myanmar and Nigeria. Women's experiences of mistreatment and satisfaction with care during childbirth was explored. Multivariable logistic regression modelling was conducted to evaluate the association between mistreatment, women's overall satisfaction with the care they received, and whether they would recommend the facility to others.

RESULTS

2672 women were included in this analysis. Despite over one-third of women reporting experience of mistreatment (35.4%), overall satisfaction for services received and recommendation of the facility to others was high, 88.4% and 90%, respectively. Women who reported experiences of mistreatment were more likely to report lower satisfaction with care: women were more likely to be satisfied if they did not experience verbal abuse (adjusted OR (AOR) 4.52, 95% CI 3.50 to 5.85), or had short waiting times (AOR 5.12, 95% CI 3.94 to 6.65). Women who did not experience any physical or verbal abuse or discrimination were more likely to recommend the facility to others (AOR 3.89, 95% CI 2.98 to 5.06).

CONCLUSION

Measuring both women's experiences and their satisfaction with care are critical to assess quality and provide actionable evidence for quality improvement. These measures can enable health systems to identify and respond to root causes contributing to measures of satisfaction.

Outcomes of a multifaceted intervention to improve maternal satisfaction with care in secondary hospitals in Nigeria

Background: Data in Nigeria suggests a high level of dissatisfaction among women attending maternity care in health facilities due to long wait times, disrespectful care, and poor attention by healthcare personnel. Objective: To examine the effectiveness of a multifaceted intervention in improving self-reported indicators of maternal healthcare satisfaction by women who use referral facilities in two regions of Nigeria. Method: The design was quasi-experimental and consisted of two intervention facilities and two control facilities. The interventions included strategic planning, staff re-training, a computerized appointment system, health education/feedback, maternal death reviews and surveillance, and advocacy. A random sample of 2262 women was selected (1205 in the intervention sites and 1057 in the two control sites) to respond to a 24-item questionnaire on service satisfaction as they exited the health facilities. Adjusted Poisson and binary regression analyses were used to assess and compare proportions of reported satisfaction by women between the intervention and control sites. Results: Women in the intervention sites were 54% more likely than those in control sites to report overall satisfaction with services. They were significantly less likely to report inadequate security arrangements in accessing the health facilities (p < .1); and three times more likely to agree that health workers were extremely thorough and careful in attending to them (p < .1). Conclusion: The interventions had positive effects on improving women's satisfaction with care. The findings from this study have implications for the design and implementation of interventions that address women's concerns relating to the provision of care and consequently improve service utilization.

The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study

BACKGROUND

Amid efforts to improve the quality of care for women and neonates during childbirth, there is growing interest in the experience of care, including respectful care practices. However, there is little research on the prevalence of practices that might constitute mistreatment of neonates. This study aims to describe the care received by neonates up to 2 h after birth in a sample of three countries in west Africa.

METHODS

Data from this multicountry, facility-based, observational study were collected on 15 neonatal care practices across nine facilities in Ghana, Guinea, and Nigeria, as part of WHO's wider multicountry study on how women are treated during childbirth. Women were eligible if they were admitted to the participating health facilities for childbirth, in early established labour or active labour, aged 15 years or older, and provided written informed consent on behalf of themselves and their neonate. All labour observations were continuous, one-to-one observations of women and neonates by independent data collectors. Descriptive statistics and multivariate logistic regressions were used to examine associations between these neonatal care practices, maternal and neonate characteristics, and maternal mistreatment. Early neonate deaths, stillbirths, and higher order multiple births were excluded from analysis.

FINDINGS

Data collection took place from Sept 19, 2016, to Feb 26, 2017, in Nigeria; from Aug 1, 2017, to Jan 18, 2018, in Ghana; and from July 1 to Oct 30, 2017, in Guinea. We included data for 362 women-neonate dyads (356 [98%] with available data for neonatal care practices) in Nigeria, 760 (749 [99%]) in Ghana, and 558 (522 [94%]) in Guinea. Delayed cord clamping was done for most neonates (1493 [91·8%] of 1627); other practices, such as skin-to-skin contact, were less commonly done (1048 [64·4%]). During the first 2 h after birth, separation of the mother and neonate occurred in 844 (51·9%) of 1627 cases; and was more common for mothers who were single (adjusted odds ratio [AOR; adjusting for country, maternal age, education, marital status, neonate weight at birth, and neonate sex] 1·8, 95% CI 1·3-2·6) than those who were married or cohabiting. Lack of maternal education was associated with increased likelihood of neonates not receiving recommended breastfeeding practices. Neonates with a low birthweight (<2·5 kg) were more likely (1·7, 1·1-2·8) to not begin breastfeeding on demand than full weight neonates. When women experienced physical abuse from providers within 1 h before childbirth, their neonates were more likely to be slapped (AOR 1·9, 1·1-3·9).

INTERPRETATION

A high proportion of neonates did not receive recommended care practices, and some received practices that might constitute mistreatment. Further research is needed on understanding and measuring mistreatment to improve care, including respectful care, for mothers and neonates.

FUNDING

US Agency for International Development, and the UNDP/UN Population Fund/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.

Strengthening research capacity through regional partners: the HRP Alliance at the World Health Organization

BACKGROUND

Improvements in health cannot occur without cutting-edge research informing the design and implementation of health programmes and policies, highlighting the need for qualified and capable researchers and institutions in countries where disease burden is high and resources are limited.

MAIN BODY

Research capacity strengthening efforts in low- and middle-income countries have included provision of training scholarships for postgraduate degrees, often in high-income countries, internships at research universities/centres, short courses, as well as involvement with research groups for hands-on experience, among others. The HRP Alliance provides opportunities for developing local research capacity in sexual and reproductive health and rights through institutions based in low- and middle-income countries linked with ongoing and past collaborative studies. It is a network of HRP research partner institutions, World Health Organization (WHO) country and regional offices, WHO special programmes and partnerships, and WHO collaborating centres.

CONCLUSION

It is through the HRP Alliance that HRP seeks to improve population health by strengthening local research capacity in sexual and reproductive health across the globe, with focus in low- and middle-income countries, in alignment with WHO's quest of promoting healthier populations.