Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study

Knowledge, attitude and practice of healthcare providers on mistreatment of women during labour and childbirth: A cross-sectional study in Tehran, Iran, 2021

BACKGROUND

Mistreatment of women during childbirth is a global health challenge. Maternity healthcare providers play a key role in influencing women's birth experience. This study aimed to assess the knowledge, attitudes, and practices of healthcare providers regarding mistreatment of women during labour and childbirth in public hospitals in Tehran, Iran.

METHODS

This cross-sectional study was part of an implementation research project that was conducted from October to December 2021 at five public teaching hospitals in Tehran. All eligible maternity healthcare providers (obstetricians and midwives) and students were invited to participate in this study. Data were collected using a questionnaire consisting of four sections: socio-demographic characteristics (11 items), knowledge (11 items), attitudes (13 items), and practices (14 items) about mistreatment. Knowledge, attitude, and practice scores were determined using Bloom's cut-off points. Logistic regression analyses were used to identify the socio-demographic characteristics associated with knowledge and attitudes. A p-value of <0.05 was considered statistically significant.

RESULTS

Of the 270 participants, 255 (94.5%) participated in the study. Majority of the participants (82.7%) had poor knowledge regarding mistreatment of women during labour and childbirth. Poor knowledge was more apparent in the categories of physical abuse, verbal abuse, poor rapport between women and providers, and failure to meet professional standards of care. Most participants (69.4%) had poor attitudes towards mistreatment; they were alright with physical abuse, verbal abuse, and discrimination. Only 3.1% of the participants reported moderate mistreatment practices towards birthing women. Verbal and physical abuse were the most prevalent categories used by the participants. The number of night shifts was associated with attitudes regarding mistreatment (AOR = 0.45, 95% CI = 0.22-0.89, p = 0.02).

CONCLUSION

The knowledge and attitude of our participants regarding maternity mistreatment were poor. A small percentage of the participants reported mistreatment practices. The findings of our study have important implications for program planners and decision-makers in developing effective interventions to reduce mistreatment of women during labour and childbirth in Iran.

Healthcare providers' perspectives on sustaining respectful maternity care appreciated by mothers in five hospitals of Rwanda

BACKGROUND

Childbirth reserves respect, as emphasized by the World Health Organization in 2018, and the focus towards the need for positive, dignified delivery experiences has become an integral aspect of Respectful Maternity Care (RMC). It is a known fact that RMC is pivotal for favourable birth outcomes and contributes to the satisfaction of maternity care. The absence of RMC negatively affects women's and newborns' rights. The study aimed to explore healthcare providers' perspectives on sustaining RMC actions that mothers previously reported.

METHODOLOGY

This study was conducted in five hospitals in the Eastern province of Rwanda, involving 5 Focus Group Discussions (FGDs) with midwives and nurses. For interviews, we purposively selected 5-unit managers and five physicians. Additionally, 40 midwives and nurses were recruited for the FGDs. The research utilized the Dream phase of Appreciative Inquiry (AI) for interviews and Focus Groups. Data collection aimed to gain insights into Healthcare Providers' perceptions of how RMC is provided and how to establish and sustain RMC in Rwandan health facilities. Nvivo 12 was employed for organizing codes and creating a codebook, and thematic analysis was applied.

RESULTS

Four themes with sub-themes emerged. Namely, 1) Women-centered care, with Compassionate care, Privacy and confidentiality maintenance, Information provision and Liberty in decision making, Effective communication, Family involvement, Cleanliness, and Equality care. 2) Professionalism compliance with Motivated staff, Teamwork, Continuous development, Quality work provision, and Community trust. 3) RMC encounters 4) RMC sustenance.

CONCLUSION AND RECOMMENDATIONS

The continuous pursuit of high RMC standards in Rwanda involves improving childbirth experiences through utilizing existing resources, ongoing improvement, and sustaining achievements. Key recommended actions in this study for sustaining RMC encompass promoting women-centred care, enhancing healthcare provider attitudes, ensuring professionalism, building community trust, maintaining conducive health facility environments, and involving leadership.

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.

Respectful maternity care interventions to address women mistreatment in childbirth: What has been done?

INTRODUCTION

Over the last decade, there has been an increasing number of studies regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing severe postpartum depression among the women who experienced them. This constitutes a serious violation of human rights. However, few studies have carried out specifically designed interventions to reduce these practices. The aim of this scoping review is to synthetise available evidence on this subject, and to identify initiatives that have succeeded in reducing the mistreatment, D&A that women suffer during childbirth in health facilities.

METHODS

A PubMed search of the published literature was conducted, and all original studies evaluating the efficacy of any type of intervention specifically designed to reduce these negative experiences and promote RMC were selected.

RESULTS

Ten articles were included in this review. Eight studies were conducted in Africa, one in Mexico, and the other in the U.S. Five carried out a before-and-after study, three used mixed-methods, one was a comparative study between birth centres, and another was a quasi-experimental study. The most common feature was the inclusion of some sort of RMC training for providers at the intervention centre, which led to the conclusion that this training resulted in an improvement in the care received by the women in childbirth. Other strategies explored by a small number of articles were open maternity days, clinical checklists, wall posters and constant user feedback.

DISCUSSION

These results indicate that there are promising interventions to reduce D&A and promote RMC for women during childbirth in health facilities. RMC training for providers stands as the most proven strategy, and the results suggest that it improves the experiences of care received by women in labour.

CONCLUSION

The specific types of training and the different initiatives that complement them should be evaluated through further scientific research, and health institutions should implement RMC interventions that apply these strategies to ensure human rights-based maternity care for women giving birth in health facilities around the world.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

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.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

Exploring Jordanian mothers' experiences of childbirth

AIM

To explore the experiences of Jordanian mothers who gave birth in three public hospitals.

DESIGN

A descriptive qualitative research design was used.

METHODS

Purposive sampling was used to choose the study participants. Semi-structured one-to-one in-depth interviews were conducted with twenty postpartum mothers who had recently given birth at three public hospitals and agreed to participate in the study. Thematic content analysis (TCA) was used to analyze the data and to identify the main themes.

FINDINGS

Three major themes were generated from the data collected: (1) Mothers' experiences of dehumanization and lack of dignity during childbirth; (2) Mothers' experiences of lack of privacy during childbirth; (3) Childbirth practices.

CONCLUSION AND IMPLICATIONS

This study explored the childbirth experiences of Jordanian mothers. This study found that the childbirth experience of mothers under study was not satisfactory. Many outdated childbirth practices are still widely used by healthcare providers. The results of this study should be an alarm to review on the quality of the maternal care services in Jordan hospitals.

Measuring disrespect and abuse during childbirth in a high-resource country: Development and validation of a German self-report tool

INTRODUCTION

Increasing evidence on disrespect and abuse during childbirth has led to growing concern about the quality of care childbearing women are experiencing. To provide quantitative evidence of disrespect and abuse during childbirth services in Germany a validated measurement tool is needed.

RESEARCH AIM

The aim of this research project was the development and psychometric validation of a survey tool in the German language that measures disrespect and abuse of women during childbirth.

METHODS

A survey tool was created including the following measures: German adaptations of the short and long form of the "Mothers on Respect" (MOR) index (MOR-7 and MOR-G); the "Mothers' Autonomy in Decision Making" (MADM) scale; a mistreatment-index (MIST-I) comprising indicators of mistreatment during childbirth; and a set of items that measure experiences of discrimination during maternity care. Internal consistency reliability and construct validity of the scales were assessed using Cronbach's alpha, unweighted least squares factor analysis and non-parametric correlation analysis with a scale that measures a related construct, the Posttraumatic Symptom Scale - Self Report (PSS-SR) scale. We distributed the survey online, recruiting through snowball sampling via social media. A selection bias towards women who had experienced disrespect and abuse during their birth was intended and expedient for tool validation. The final sample of participants (n = 2045) had given birth in Germany between 2009 and 2018.

FINDINGS

More than 77% of the study participants reported at least one form of mistreatment with non-consented care being the most commonly reported type of mistreatment, followed by physical violence, violation of physical privacy, verbal abuse and neglect. All included scales showed good psychometric properties with high Cronbach's alphas (0.95 for both MOR versions and 0.96 for MADM). Factor analysis generated one factor scales with high factor loadings (0.75 to 0.92 for MOR-7; 0.37 to 0.90 for MOR-G and 0.83 to 0.92 for MADM). MOR-7, MOR-G, MADM and MIST-I scores were significantly (p<0.001) correlated with PSS-SR scores (Spearman's rho -0.70, -0.61 and 0.68 for MOR-G, MADM and the MIST-I, respectively).

CONCLUSIONS

This study presents a valid and reliable instrument for the quantitative assessment of disrespect and abuse during childbirth in Germany. Childbearing women's experiences of disrespect and abuse are a relevant phenomenon in German hospital based maternity care. Disrespect and abuse during childbirth appear to contribute to post-traumatic symptoms and may be associated with severe mental health problems postpartum.

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.

Impacts of disrespectful care and abusive care practices in maternity units and potential interventions to improve the quality of care in low- and middle-income countries: A narrative review

This review article explored the impacts of disrespectful care and abusive care practices and the potential interventions to eliminate those practices. Respectful maternity care is a fundamental right for all women. It ensures that women are able to exercise their rights in maternity care. However, research studies have shown the recent prevalence of poor-quality care for women in maternity units in low- and middle-income countries. The literature on this topic was searched on PubMed, Medline, Google Scholar, Cochrane, Science Direct/ Elsevier, and SCOPUS. A total of 24 qualitative and quantitative research articles were included. Thematic analysis was conducted by using the six steps. Impacts are coded on topics including psychological impacts due to disrespectful and abusive care practices, impact on the care process, normalization of the absence of care, suppression of knowledge regarding the labor process, and poor obstetric outcomes. Interventions are coded on topics including programs for health professionals to improve care, education and empowerment programs targeting the women and community, enacting policies and guidelines regarding disrespectful and abusive care practices and improving the facilities in the healthcare system. The majority of the evidenced-based interventions were multi-component and tailored to the needs of a particular setting. More research evidence is needed to inform the healthcare authorities and policymakers to transform these potential interventions into practice. Future research should clearly document the effectiveness of various combinations of interventions, feasibility, cost-effectiveness, and outcomes.

Promoting Supportive and Respectful Maternity Care in Public Health Facilities in Sindh, Pakistan: A Theory-Informed Health System Intervention

BACKGROUND

Disrespect, abuse, discrimination, and lack of emotional support characterize intrapartum care in the health systems of many low- and middle-income countries. Although the World Health Organization (WHO) provides frameworks and guidelines to address this issue, no operational model exists that effectively incorporates WHO intrapartum care guidelines into routine public health services. We aimed to develop and pilot-test a theory-driven, service-delivery intervention package linking dignified care with perinatal mental health to promote psychosocially supportive and respectful maternity care (S-RMC) in public health facilities in Sindh, Pakistan.

METHODS

Using a mixed-method, pre-post design, the study was implemented in 6 secondary-level public health facilities in 2 rural districts of Southern Sindh, Pakistan. Its development was guided by the COM-B framework and informed by a literature review, formative research, and consultative sessions with implementers. The intervention was implemented in March-September 2021 and compared women's experiences of S-RMC during childbirth at baseline (n=313) and endline (n=314). We used descriptive statistics and linear regression techniques for analysis.

RESULTS

A substantial reduction was observed in the cumulative level of overall mistreatment from baseline to endline, yielding a relative change of 50% (P<.001). Similar change was evident across different types of mistreatment: physical abuse (75%), verbal abuse (72%), ineffective communication (60%), nonconfidential care (78%), health system conditions and constraints (25%), noninclusive care (28%), lack of supportive care (52%), and stigma and discrimination (82%). Furthermore, we observed a significant reduction in the proportion of women experiencing symptoms of anxiety and depression before and after the intervention.

CONCLUSION

This intervention built the capacity of maternity teams while improving accountability, health information systems, and governance measures. Given its promise to promote supportive and respectful childbirth in public health facilities, a large-scale effectiveness evaluation across diverse settings is warranted.

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.

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.

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.

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.

Analysis of the social acceptability of a humanized childbirth intervention in Senegal: A qualitative study

BACKGROUND

In efforts to improve the quality of women's care and enhance related experiences in Senegal, the Senegalese government implemented an intervention named "humanized childbirth" in their health facilities.

AIM

To analyze the social acceptability of humanized childbirth as well as its relevance given the social values in Senegal.

METHODS

A multiple-case study was conducted within four health facilities in Dakar. Breastfeeding mothers (n = 20), pregnant women (n = 4), midwives (n = 8), Bajenu Gox (n = 4), members of the Health Development Committee (n = 4), and men from the community (n = 4) were interviewed individually, and a documentary analysis was done. The thematic analysis was performed using the acceptability theoretical framework.

FINDINGS

The results show that most participants agreed with the idea of humanized childbirth. However, participants display varying viewpoints as to the social acceptability of various components of the intervention. While there is an overall agreement concerning the benefits of motivated and attentive health professionals focused on prevention, restoring dignity for the parturient woman, freedom to eat and drink, massages and relaxation, the same cannot be said about the freedom of choice for birth positions and companionship.

DISCUSSION

The contrasting viewpoints as to the acceptability of humanized childbirth can be explained by the perception of risk and lack of experience with free birthing positions, as well as structural and cultural barriers surrounding the notion of companionship.

CONCLUSION

Education and awareness of the benefits of free birthing positions and companionship would be required among Senegalese women to enable a cultural shift in maternity wards in Senegal.

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

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

Systematic Review Registration

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

Charge midwives' awareness of and their role in promoting respectful maternity care at a tertiary health facility in Ghana: A qualitative study

BACKGROUND

Evidence suggests that the implementation of respectful maternity care (RMC) interventions is one of the surest and most effective means of minimising mistreatment during intrapartum care services. However, to ensure the successful implementation of RMC interventions, maternity care providers would have to be aware of RMC, its relevance, and their role in promoting RMC. We explored the awareness and role of charge midwives in promoting RMC at a tertiary health facility in Ghana.

METHODS

The study adopted an exploratory descriptive qualitative study design. We conducted nine interviews with charge midwives. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses.

RESULTS

The study revealed that charge midwives are aware of RMC. Specifically, ward-in-charges perceived RMC as consisting of showing dignity, respect, and privacy, as well as providing women-centred care. Our findings showed that the roles of ward-in-charges included training midwives on RMC and leading by example, showing empathy and establishing friendly relationships with clients, receiving and addressing clients' concerns, and monitoring and supervising midwives.

CONCLUSION

We conclude that charge midwives have an important role to play in promoting RMC, which transcends simply providing maternity care. Policymakers and healthcare managers should ensure that charge midwives receive adequate and regular training on RMC. This training should be comprehensive, covering aspects such as effective communication, privacy and confidentiality, informed consent, and women-centred care. The study also underscores a need for policymakers and health facility managers to prioritise the provision of resources and support for the implementation of RMC policies and guidelines in all healthcare facilities. This will ensure that healthcare providers have the necessary tools and resources to provide RMC to clients.

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.

Measurement of self-reported, facility-based labour and birth experiences: The Perinatal Experience Assessment Tool (PEAT)

Background

Women and their families make decisions on accessing perinatal care based on their experiences in the health care system and on the experience of others around them. Receiving supportive maternity care which demonstrates respect is an essential part of quality care. Globally, and in low- and middle-income countries in particular, women report receiving mistreatment and a lack of respect during labour, childbirth and the early postnatal period. These experiences, if negative, may influence choices around place of birth, thus hindering the scale-up of facility-based births.

Methods

We conducted a focussed review of the literature between 2010 and 2019 to identify recent research addressing the assessment of women's experiences during childbirth in low- and middle-income country facilities. The World Health Organization (WHO) and White Ribbon Alliance themes and concepts of respectful maternity care served as a guide. Themes included disrespectful or abusive experiences such as verbal abuse or rudeness, abandonment, corruption, lack of privacy, failure to respect traditional practices, discrimination, and physical or sexual abuse. Experienced midwives in two low-resource countries contributed to the identification of appropriate indicators of respectful, non-abusive care, and eventual agreement as to which to include in an assessment tool monitoring women's experiences.

Results

Our review of the literature identified 18 publications meeting pre-established criteria. This resulted in the eventual selection of 33 indicators of respectful care sub-grouped under 9 domains: 1) communication/verbal interaction, 2) supportive care, 3) physical abuse, 4) non-consented care, 5) non-confidential care/lack of privacy, 6) stigma and discrimination, 7) abandonment/neglect, 8) detention/inability to pay, and 9) health facility conditions. We converted these indicators into questions to be asked by an interviewer during a short interview following discharge to assess the childbirth experience.

Conclusions

The Perinatal Experience Assessment Tool (PEAT) may be used to monitor or evaluate the experiences that women report after facility-based childbirth. It can be administered by trained, independent interviewers in the facility following discharge. The PEAT enables maternity leaders to assess the extent to which maternity services are conducted in a respectful, non-abusive manner and modify practices and procedures as feasible and appropriate.

Organisational and individual readiness for change to respectful maternity care practice and associated factors in Ibadan, Nigeria: a cross-sectional survey

OBJECTIVES

This study assessed health providers' organisational and individual readiness for change to respectful maternity care (RMC) practice and their associated factors in Ibadan Metropolis, Nigeria.

DESIGN

A cross-sectional survey using standardised structured instruments adapted from the literature.

SETTING

Nine public health facilities in Ibadan Metropolis, Nigeria, 1 December 2019-31 May 2020.

PARTICIPANTS

212 health providers selected via a two-stage cluster sampling.

OUTCOMES

Organisational readiness for change to RMC (ORCRMC) and individual readiness for change to RMC (IRCRMC) scales had a maximum score of 5. Multiple linear regression was used to identify factors influencing IRCRMC and ORCRMC. We evaluated previously identified predictors of readiness for change (change valence, informational assessments on resource adequacy, core self-evaluation and job satisfaction) and proposed others (workplace characteristics, awareness of mistreatment during childbirth, perceptions of women's rights and resource availability to implement RMC). Data were adjusted for clustering and analysed using Stata V.15.

RESULTS

The providers' mean age was 44.0±9.9 years with 15.4±9.9 years of work experience. They scored high on awareness of women's mistreatment (3.9±0.5) and women's perceived rights during childbirth (3.9±0.5). They had high ORCRMC (4.1±0.9) and IRCRMC (4.2±0.6), both weakly but positively correlated (r=0.407, 95% CI: 0.288 to 0.514, p<0.001). Providers also had high change valence (4.5±0.8) but lower perceptions of resource availability (2.7±0.7) and adequacy for implementation (3.3±0.7). Higher provider change valence and informational assessments were associated with significantly increased IRCRMC (β=0.40, 95% CI: 0.11 to 0.70, p=0.015 and β=0.07, 95% CI: 0.01 to 0.13, p=0.032, respectively), and also with significantly increased ORCRMC (β=0.47, 95% CI: 0.21 to 0.74, p=0.004 and β=0.43, 95% CI: 0.22 to 0.63, p=0.002, respectively). Longer years of work experience (β=0.08, 95% CI: 0.01 to 0.2, p=0.024), providers' monthly income (β=0.08, 95% CI: 0.02 to 0.15, p=0.021) and the health facility of practice were associated with significantly increased ORCRMC.

CONCLUSION

The health providers studied valued a change to RMC and believed that both they and their facilities were ready for the change to RMC practice.

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

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

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.

Parent-Reported Experience Measures of Care for Children With Serious Illnesses: A Scoping Review

OBJECTIVE

This scoping review aimed to: 1) identify parent-reported experience measures (PaREMs) for parents of children with serious illnesses from peer-reviewed literature, 2) map the types of care experience being evaluated in PaREMs, 3) identify and describe steps followed in the measure development process, including where gaps lie and how PaREMs may be improved in future efforts, and 4) help service providers choose a PaREM suitable for their service delivery setting and strategy.

DATA SOURCES

Relevant articles were systematically searched from PubMed, CINAHL, and Scopus EBSCOhost databases until June 10, 2021, followed by a manual reference list search of highly relevant articles.

STUDY SELECTION

Abstracts were screened, followed by a full-text review using predetermined inclusion and exclusion criteria.

DATA EXTRACTION

A standardized data extraction tool was used.

DATA SYNTHESIS

Sixteen PaREMs were identified. There were large variances in the development processes across measures, and most have been developed in high-income, English-speaking Western countries. Most only assess the quality of acute inpatient care. Few measures can be used by multiple service providers or chronic care, and many do not capture all relevant domains of the parent experience.

CONCLUSIONS

Service providers should integrate PaREMs into their settings to track and improve the quality of care. Given the multidisciplinary nature of pediatric care and the often-unpredictable disease trajectories of seriously ill children, measures that are applicable to multiple providers and varying lengths of care are essential for standardized assessment of quality of care and coordination among providers. To improve future PaREM development, researchers should follow consistent and methodologically robust steps, ideally in more diverse sociocultural and health systems contexts. Future measures should widen their scope to be applicable over the disease trajectory and to multiple service providers in a child's network of care for a comprehensive evaluation of experience.

Clients satisfaction at primary healthcare facilities and its association with implementation of client service charter in Tanzania

Background

Client service charter (CSC) provides information about what people can expect in a facility’s services; what is expected of clients and service providers. Tanzania implemented Star Rating Assessment (SRA) of primary health care (PHC) facilities in 2015/16 and 2017/18 using SRA tools with 12 service areas. This paper assesses the status of service area 7, namely client focus that checked if client was satisfied with services provided and implementation of CSC through three indicators–if: CSC was displayed; CSC was monitored; client feedback mechanism and complaints handling was in place.

Methods

We extracted and performed a cross-sectional secondary data analysis of data related to clients’ focus that are found in national SRA database of 2017/2018 using STATA version 15. Client satisfaction was regarded as dependent variable while facility characteristics plus three indicators of CSC as independent variables. Multivariate logistic regression with p-value of 5% and 95% confidence interval (CI) were applied.

Results

A total of 4,523 facilities met our inclusion criteria; 3,987 (88.2%) were dispensaries, 408 (9.0%) health centres and 128 (2.8%) hospitals. CSC was displayed in 69.1% facilities, monitored in 32.4% facilities, and 32.5% of the facilities had mechanisms for clients’ feedback and handling complaints. The overall prevalence of clients’ satisfaction was 72.8%. Clients’ satisfaction was strongly associated with all implementation indicators of CSC. Clients from urban-based facilities had 21% increased satisfaction compared rural-based facilities (AOR 1.21; 95%CI: 1.00–1.46); and clients from hospitals had 39% increased satisfaction compared to dispensaries (AOR 1.39; 95%CI: 1.10–1.77).

Conclusion

The implementation of CSC is low among Tanzanian PHC facilities. Clients are more satisfied if received healthcare services from facilities that display the charter, monitor its implementation, have mechanisms to obtain clients feedback and handle complaints. Clients’ satisfaction at PHC could be improved through adoption and implementation of CSC.

"Taking care of your pregnancy": a mixed-methods study of group antenatal care in Kakamega County, Kenya

BACKGROUND

Traditional antenatal care (ANC) models often do not meet women's needs for information, counseling, and support, resulting in gaps in quality and coverage. Group ANC (GANC) provides an alternative, person-centered approach where pregnant women of similar gestational age meet with the same health provider for facilitated discussion. F studies show associations between GANC and various outcomes.

METHODS

We employed a pre-post quasi-experimental design using mixed methods to assess a GANC model (Lea Mimba Pregnancy Clubs) at six health facilities in Kakamega County, Kenya. Between April 2018 and January 2019, we tracked 1652 women assigned to 162 GANC cohorts. Using an intention-to-treat approach, we conducted baseline (N = 112) and endline surveys (N = 360) with women attending immunization visits to assess outcomes including experience of care, empowerment and self-efficacy, knowledge of healthy practices and danger signs, and practice of healthy behaviors, including ANC retention. At endline, we conducted 29 in-depth interviews (IDIs) and three focus group discussions with women who were currently and previously participating in GANC, and 15 IDIs with stakeholders.

RESULTS

The proportion of survey respondents with knowledge of three or more danger signs during pregnancy more than tripled, from 7.1% at baseline to 26.4% at endline (OR: 4.58; 95% CI: 2.26-10.61). We also found improvements in women's reports about their experience of care between baseline and endline, particularly in their assessment of knowledge and competence of health workers (OR: 2.52 95% CI: 1.57-4.02), respect shown by ANC providers (OR: 1.82, 95% CI: 1.16-2.85), and women's satisfaction with overall quality of care (OR: 1.62, 95% CI: 1.03-2.53). We saw an increase from 58.9% at baseline to 71.7% at endline of women who strongly agreed that they shared their feelings and experiences with other women (OR: 1.73, 95% CI: 1.1-2.7). The mean number of ANC visits increased by 0.89 visits (95% CI: 0.47-1.42) between baseline (4.21) and endline (5.08). No changes were seen in knowledge of positive behaviors, empowerment, self-efficacy, and several aspects related to women's experience of care and adoption of healthy behavior constructs. Qualitatively, women and stakeholders noted improved interactions between health providers and women, improved counseling, increased feelings of empowerment to ask questions and speak freely and strengthened social networks and enhanced social cohesion among women.

CONCLUSIONS

GANC offers promise for enhancing women's experience of care by providing improved counseling and social support. Additional research is needed to develop and test measures for empowerment, self-efficacy, and experience of care, and to understand the pathways whereby GANC effects changes in specific outcomes.

Promoting respectful maternity care using a behavioral design approach in Zambia: results from a mixed-methods evaluation

Background

Respectful maternity care (RMC) has been elevated in the global discourse, however, instances of disrespect and abuse remain prevalent. While several studies have highlighted promising approaches to promote RMC, this body of literature is still limited and few approaches have been scaled outside the initial study sites. Building on formative research conducted through a behavioral science lens, we sought to develop and test evidence-based, low-cost solutions to promote RMC which would be well-positioned for scale-up. Our study highlights the effectiveness of the solution package on provider provision of respectful care and client satisfaction, as well as intermediary outcomes and behavioral mechanisms.

Methods

A quasi-experimental evaluation, informed by the behavioral design approach, was completed to test the effectiveness of a 5-component solution package in Chipata, Zambia. Quantitative surveys were collected from health facility providers and postpartum clients at baseline and endline in intervention and comparison facilities. Additional qualitative interviews were conducted with health facility providers and postpartum clients at endline. We also conducted interviews with health facility in-charges and observed labor and delivery practices at intervention facilities over the course of implementation.

Results

Evidence suggested that at endline, clients at implementation facilities were less likely to experience disrespect and abuse compared to clients at comparison facilities (ß = − 0.15 p = 0.01). Clients at intervention facilities were more likely to request pain management compared to clients at comparison facilities (ß = 0.33, p = 0.003). The solutions were simple for providers to implement and were easily integrated into existing services by providers during labor and delivery. Providers at intervention facilities also described the pain management toolkit as helpful in expanding the types of pain management techniques used during labor.

Conclusions

The results of this small-scale study act as a proof of concept, demonstrating that the behavioral design approach can lead to solutions that show potential for impact. In other settings where providers face similar barriers to providing RMC, an adaptation of this solution package might lead to similarly positive results. Given the global scale of disrespectful care, these low-cost solutions hold promise for improving the quality of care women receive during labor and delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01447-1.

Instances of disrespect and abuse during childbirth are prevalent around the world, particularly in low-resource settings. Few interventions have been designed and evaluated in these settings and even fewer in Southern Africa. This study aimed to understand the effects of a behaviorally informed intervention on the provision of respectful maternity care. We performed an evaluation of a health facility-based intervention, in Chipata District, Zambia. The study included quantitative and qualitative surveys with health care providers and women who recently delivered, as well as health facility observations and qualitative interviews with health facility supervisors. Our results show that clients who delivered at a facility where our intervention took place had a decreased likelihood of experiencing disrespect and abuse and an increased provision of pain management support. Our findings suggest that facility-based approaches informed by behavioral science have the potential to increase provision of respectful care and decrease the prevalence of mistreatment in low-resource settings. A large-scale evaluation of these interventions across settings could contribute valuable evidence around low-cost solutions to promote respectful maternity care.

Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana

Background

Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives’ perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility.

Methods

We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study.

Results

The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO’s quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building.

Conclusion

We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04786-w.

Respectful delivery care and associated factors among mothers delivered in public health facilities of Dessie city, Northeast Ethiopia: a cross-sectional study

Background

The government of Ethiopia has been implementing compassionate, respectful, and caring strategies to increase institutional delivery and decrease maternal mortality in recent years. There is limited evidence on respectful delivery care and associated factors in low-income countries like Ethiopia. Therefore, this study aimed to assess the proportion of respectful delivery care and associated factors among mothers delivered in the health facilities of Dessie city, Northeast Ethiopia.

Methods

A health facility-based cross-sectional study was conducted among a total of 390 mothers from April 16 to May 30, 2018. A pretested structured interviewer-administered questionnaire was used to collect the data. The data were entered into Epidata and analyzed using Stata/SE 14. Binary logistic regression analysis was used to identify associated factors. Variables having P-value less than 0.2 in the bivariable regression were selected as a candidate for multi-variable regression. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was estimated to measure the strength and direction of the association respectively.

Results

The proportion of respectful delivery care among mothers delivered in public health facilities of Dessie city was 43.4%, 95% CI (39.1%, 47.6%). It was found to be 34.9% in hospital and 74.1 in health center. Respectful delivery care was associated with day time delivery [AOR = 2.23, 95% CI (1.30, 3.82)], any maternal and/or fetal complications [AOR = 0.50, 95% CI (0.27, 0.94)], gave birth in health center [AOR = 3.22, 95% CI (1.61, 6.46)] and educated mothers [AOR = 2.87, 95% CI (1.18, 7.01)].

Conclusions

The proportion of respectful delivery care in the study area was low as compared to the government emphasis and other works of literature. This study indicated that any maternal and/or newborn complications, daytime delivery, giving birth in a health center, and maternal education were associated with respectful delivery care. Women empowerment through education could be a recalled intervention for respectful care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01713-1.

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.

Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures, and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020183440.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review

BACKGROUND

Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation.

METHODS

Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors.

RESULTS

Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area.

CONCLUSIONS

Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

Lay and healthcare providers' experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: an Appreciative Inquiry

OBJECTIVES

Disrespectful care, which remains prevalent in low and middle-income countries (LMICs), acts as a barrier to women accessing skilled birth attendance, compromising care when services are available. Building on what was positive in facilities, we aimed to explore lay and healthcare providers' experience of respectful care to inform future interventions.

SETTING

Five maternity facilities in Mwanza Tanzania and Lilongwe Malawi.

PARTICIPANTS

94 participants in Malawi (N=46) and Tanzania (N=48) including 24 women birthing live baby within the previous 12 months; 22 family members and 48 healthcare providers who regularly provided maternity care in the included facilities DESIGN: The study was guided by Appreciative Inquiry (AI). Semistructured, one-to-one interviews were conducted between January and December 2019. Interviews were audio-recorded, translated where necessary, transcribed verbatim, and analysed using the framework approach.

RESULTS

Four main themes describing participants positive experience and their vision of respectful care were identified: (1) empathic healthcare provider-woman interactions including friendly welcome and courteous language, well-timed appropriate care and information sharing, (2) an enabling environment, characterised by improvement of physical environment, the use of screens, curtains and wall partitions for privacy, availability of equipment and provision of incentives to staff, (3) supportive leadership demonstrated by the commitment of the government and facility leaders to provision of respectful care, ensuring availability of guidelines and policies, supportive supervision, reflective discussion and paying staff salaries timely, (4) providers' attitudes and behaviours characterised by professional values through readiness, compassionate communication and commitment.

CONCLUSION

The positive experiences of service users, families and healthcare providers provided insight into key drivers of respectful care in facilities in Tanzania and Malawi. Interventions targeting improved environment and privacy, healthcare provider communication and developing positive leadership structures in facilities could provide the basis for sustained improvement in respectful and dignified maternal and newborn care in LMICs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

"Even when people live just across the road…they won't go": Community health worker perspectives on incentivized delays to under-five care-seeking in urban slums of Kampala, Uganda

Background

Although under-five (U5) mortality in Uganda has dropped over the past two decades, rates in urban slum neighborhoods remain high. As part of a broader verbal and social autopsy study of U5 deaths, this study explored the perspectives of volunteer community health workers, called Village Health Teams (VHTs), on why children under five in Kampala’s informal settlements are still dying despite living in close proximity to nearby health facilities.

Methods

This exploratory, qualitative study took place between January and March 2020 in the Rubaga division of Kampala, Uganda. VHTs from the slums of Kawaala and Nankulabye parishes, both located near a large government health center, were interviewed by a trained local interviewer to determine their perceptions of barriers to care-seeking and attribution for U5 childhood deaths. All interviews were audiotaped, transcribed into English, imported into NVivo V 12.0 and thematically analyzed using the Attride-Stirling framework.

Results

20 VHTs were interviewed, yielding two global themes, the first focusing on VHTs perceptions of their role in the community to promote positive health outcomes, and the second focusing on VHTs’ perceptions of how prompt care-seeking is disincentivized. Within the latter theme, three inter-related sub-themes emerged: disincentives for care-seeking at the health system level, which can drive negative beliefs held by families about the health system, and in turn, drive incentives for alternative health behaviors, which manifest as “incentivized delays” to care-seeking.

Discussion

This study illustrates VHT perspectives on the complex interactions between health system disincentives and the attitudes and behaviors of families with a sick child, as well as the reinforcing nature of these factors. Findings suggest a need for multi-pronged approaches that sensitize community members, engage community and health system leadership, and hold providers accountable for providing high-quality care. VHTs have enormous potential to foster improvement if given adequate resources, training, and support.

Re-examining Norms of Disrespect and Abuse in the Second Stage of Labor in Tanzanian Maternity Care

Globally, the widespread occurrence of disrespect and abuse (D&A) on maternity wards is well-documented. Using ethnography and cultural consensus analysis we explore how the practice of midwives hitting women who are in the second stage of labor (pushing) has become a locally accepted form of care in Tanzania if a baby's life appears to be at risk. This analysis interrogates the deep uncertainty of birth outcomes in this setting that may motivate abuse during this time. Seriously engaging with local discourses on abuse and care sheds light on hegemonic norms and power dynamics and is critical for improving maternity services.

Midwives' experiences of implementing respectful maternity care knowledge in daily maternity care practices after participating in a four-day RMC training

Background

In Ghana, studies documenting the effectiveness of evidence-based specialized training programs to promote respectful maternity care (RMC) practices in healthcare facilities are few. Thus, we designed a four-day RMC training workshop and piloted it with selected midwives of a tertiary healthcare facility in Kumasi, Ghana. The present paper evaluated the impact of the training by exploring midwives’ experiences of implementing RMC knowledge in their daily maternity care practices 4 months after the training workshop.

Methods

Through a descriptive qualitative research design, we followed-up and conducted 14 in-depth interviews with participants of the RMC training, exploring their experiences of applying the acquired RMC knowledge in their daily maternity care practices. Data were managed and analysed using NVivo 12. Codes were collapsed into subthemes and assigned to three major predetermined themes.

Results

The findings have been broadly categorized into three themes: experiences of practising RMC in daily maternity care, health facility barriers to practising RMC, and recommendations for improving RMC practices. The midwives mentioned that applying the newly acquired RMC knowledge has positively improved their relationship with childbearing women, assisted them to effectively communicate with the women, and position them to recognize the autonomy of childbearing women. Despite the positive influence of the training on clinical practice, the midwives said the policy and the built environment in the hospital does not support the exploration of alternative birthing positions. Also, the hospital lacked the required logistics to ensure privacy for multiple childbearing women in the open labour ward. The midwives recommended that logistics for alternative birthing positions and privacy in the ward should be provided. Also, all midwives and staff of the hospital should be taken through the RMC training program to encourage good practice.

Conclusion

Despite the report of some RMC implementation challenges, the midwives noted that the 4-day RMC training has had a positive impact on their maternity caregiving practice in the hospital. Policies and programs aimed at addressing the issue of disrespect and abusive practices during maternity care should advocate and include the building of facilities that support alternative birthing positions and privacy of childbearing women during childbirth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00559-6.

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

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

Maternal Health Infrastructure and Interpersonal Quality of Care During Childbirth: An Examination of Facility Delivery in Malawi

OBJECTIVES

The maternal health field has recently focused on the importance of interpersonal quality of care and continues to cite structural deficits as a contributor to poor interpersonal treatment. This hypothesis is supported by qualitative evidence. This study quantitatively tested the effect of maternal health structural inputs on interpersonal quality of care during childbirth.

METHODS

Analyses were conducted using data from the 2013 to 2014 Malawi Service Provision Assessment, which documented the availability and quality of health facility services and included the observation of laboring and delivering women. Maternal health structural inputs were measured using 26 facility infrastructure variables. The outcome, interpersonal quality of care, was measured as a sum score of 12 items collected during the observations. Crude and adjusted associations between maternal health structural inputs on interpersonal quality of care were assessed using linear regression with cluster robust standard errors.

RESULTS

345 Observations of delivering women in 174 health facilities were included in the analysis. 19.1% of women delivered in a facility with high maternal health structural inputs, and the mean interpersonal quality of care score was 8.9/12. Maternal health structural inputs had a small, non-meaningful association with interpersonal quality of care during childbirth (adjusted β - 0.19, 95% CI - 0.85, 0.47).

CONCLUSIONS FOR PRACTICE

These findings do not verify the quality of care frameworks or qualitative evidence that support the relationship between structure and interpersonal quality of care. While structural inputs are important for health system performance, the results suggest that they might not be necessary for a respectful childbirth experience.

The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania

BACKGROUND

An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate.

METHODS

This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included.

RESULTS

Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels.

CONCLUSIONS

To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

Feasibility of Participatory Theater Workshops to Increase Staff Awareness of and Readiness to Respond to Abuse in Health Care: A Qualitative Study of a Pilot Intervention Using Forum Play among Sri Lankan Health Care Providers

Women globally experience mistreatment by health providers during childbirth. Researchers have identified strategies to counteract this type of abuse in health care, but few have been evaluated. We used a theater technique, Forum Play, in a brief training intervention to increase awareness of abuse in health care and promote taking action to reduce or prevent it. The intervention was implemented in four workshops with 50 participating physicians and nurses from three hospitals in Colombo, Sri Lanka. This article reports the views of 23 workshop participants who also took part in four focus group discussions on the acceptability and feasibility of the method. The participants reported that the intervention method stimulated dialogue and critical reflection and increased their awareness of the everyday nature of abuses experienced by patients. Participants appreciated the participatory format of Forum Play, which allowed them to re-enact scenarios they had experienced and rehearse realistic actions to improve patient care in these situations. Structural factors were reported as limitations to the effectiveness of the intervention, including under-developed systems for protecting patient rights and reporting health provider abuses. Nonetheless, the study indicates the acceptability and feasibility of a theater-based training intervention for reducing the mistreatment of patients by health care providers in Sri Lanka.

CLEVER maternity care: A before-and-after study of women's experience of childbirth in Tshwane, South Africa

Background

Birthing care matters to women and some women experience mistreatment during childbirth.

Aim

To determine the effect the ‘CLEVER Maternity Care’ package, a multi-faceted intervention to improve respectful, quality obstetric care.

Setting

Ten midwife-led obstetric units in Tshwane health district, South Africa; five intervention and five control units.

Methods

We conducted an anonymous baseline and end-line survey to measure the change in women’s perceptions and experiences of childbirth care after the implementation of the CLEVER package. A convenience sample of women returning for a postnatal follow-up visit was obtained at baseline (n = 653) and after implementation of CLEVER (n = 679).

Results

Six survey items were selected as proxies for respectful clinical care. There was no significant change in proportions of responses regarding one question, and with regard to patients receiving attention within 15 min of arrival, both the intervention and control group units showed a significant increase in positive responses (odds ratios of 8.4 and 6.1, respectively, and p values of 0.0001 and 0.0007). For the remaining four items (asking permission before doing an examination, positive communication, respectful treatment and overall satisfaction), only the intervention group showed a significant positive change (odds ratios ranging from 2.4 to 4.3; p ≤ 0.0018), with no significant change for the control group (odds ratios between 1.0 and 1.8; p ≥ 0.0736).

Conclusion

After the implementation of CLEVER Maternity Care, women reported a more positive experience of childbirth. The CLEVER intervention is a potential strategy for addressing respectful, quality obstetric care that warrants further investigation.

Disrespect and abuse of women during the process of childbirth at health facilities in sub-Saharan Africa: a systematic review and meta-analysis

Background

Disrespectful and abusive treatment of women by health care providers during the process of childbirth at health facility is an international problem. There is a lack of data on disrespect and abuse of women during the process of childbirth at health facilities in Sub-Saharan Africa. The purpose of this study was to determine the prevalence of disrespect and abuse of women during the process of childbirth at health facilities in sub-Saharan Africa.

Methods

The PRISMA guideline protocol was followed to write the systematic review and meta-analysis. Published studies were searched from Medline, PubMed, CINAHL, EMBASE, Maternal and infant care, science direct, and PsycINFO. Articles were accessed by three reviewers (ZY, BT and AA) using the following key terms, “attitude of health personnel” AND “delivery obstetrics*/nursing” OR “maternity care” AND “disrespect” OR “abuse” OR “professional misconduct” AND “parturition” AND “prevalence” AND “professional-patient relations” AND “Sub-Saharan Africa”. Additional articles were retrieved by cross referencing of reference. The heterogeneity of studies were weighed using Cochran’s Q test and I² test statistics. Publication bias was assessed by Egger’s test.

Results

Thirty three studies met the inclusion and included in this systematic review and meta–analysis of disrespect and abuse of women during the process of childbirth at health facilities. The pooled prevalence of disrespect and abuse women during the process of childbirth at health facilities in Sub-Saharan Africa was 44.09% (95% CI: 29.94–58.24).Particularly physical abuse was 15.77% (95% CI: 13.38–18.15), non-confidential care was 16.87% (95% CI: 14.49–19.24), abandonment was 16.86% (95% CI: 13.88–19.84) and detention was 4.81% (95% CI: 3.96–5.67).

Conclusion

In this study disrespect and abuse of women during the process of childbirth at health facilities are high compared with other studies, particularly non-confidential care and abandonment his high compared with other studies. This study points out that the ministry of health, health care providers, maternal health experts shall due attention to women’s right during the process of childbirth at health facilities.

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.