Measuring Disrespect and Abuse during Childbirth in the Western Highlands of Guatemala Emily Peca, MA, MPH GWU/USAID|TRAction Project Respectful Maternity.

Measuring Disrespect and Abuse during Childbirth in the Western Highlands of Guatemala

Emily Peca, MA, MPHGWU/USAID|TRAction Project

Respectful Maternity Care SeminarJune 24, 2014

Overview of Presentation

• Context of Guatemala• Opportunity to explore

D&A within an existing effort

• Data source• Data collection• Preliminary results• Contribution

Guatemala: Country of Contrasts

Disparities in outcomes: by ethnicity, geography, income

Key Health Indicators for GuatemalaENSMI 2008-2009

Indicator National Non -indigenous Indigenous Dept. of

Quiche

Maternal Mortality Ratio (UN 2013)

140 per 100,000 -- -- --

Infant mortality 34 30 40 40

Fertility 3.6 3.1 4.5 5.2

Facility Delivery 51% 70% 29% 20%Women < 145 cm tall 31.2% 19% 48.3% 53.9%Chronic malnutrition (under 5)

49.8% 36.2% 65.9% 72.2%

The Opportunity

TRAction Guatemala’s technical cooperation approach focused on strengthening the network of MNCH & nutrition service delivery in Ixil Health Area

Data was collected on health seeking behavior and perceptions related to maternal child health and nutrition services

Opportunity: to describe and quantify women’s experiences and perceptions of disrespect and abuse related to facility deliveries

Study Site

Ixil is comprised of 3 municipalities in the Department of El Quiche Total Pop. Ixil ~160,000

Majority of the population lives in communities of 500 people or less

Data Source

• Qualitative & quantitative data is from 15 rural to remote communities from all three municipalities of Ixil (total pop 7,757)

• Communities are categorized as close, intermediate or far to nearest delivery facility. (1 public facility in each municipality)

• Partners COTONEB; University of San Carlos

Focus Group Discussions

•Comadronas- traditional birth attendants•Women (home birth)- within last five years•Women (facility-birth)- within the last five years

Municipality Women facility birth

Women home birth

Comadronas Total

Nebaj 2 1 2 5Cotzal 2 1 2 5Chajul 2 2 1 5Total 6 4 5 15

In-depth Interviews

Municipality Comm. Leaders

Comm. Health Workers

Women Facility Birth

Total

Nebaj 3 4 3 10Cotzal 3 3 4 10Chajul 4 3 2 9Total 10 10 9 29

•Community leaders: religious leaders, leaders of dev’t committees•Community health workers: head mini-health posts in each of the 15 communities •Women (facility-birth)- within the last five years

Domains

Domains Consistent across all FGDs & IDIs• Reasons for delivering in a facility/home• Disrespect and abuse in facilities (experiences/perceptions)• Recommendations for improving facility-based services

All data was collected by bilingual (Spanish & Ixil) women from the three municipalities of Ixil

Preliminary Results: Qualitative Data

Contributors to D&A

(Adapted) Construct of

D&A

Consequences of D&A

Quotes from women who gave birth in a facility:

• “I was not attended quickly and when my baby was about to come out they pushed me without saying why, this made me feel bad.”

• “They gave me cold food and when they drew my blood they never told me why.”

• “The providers were not at my side when my baby was born …”

• I needed help and the nurse didn’t want to help me. When I asked her help she just said levantate! (get up!), but I couldn’t.”

“They are from the same group as us (Ixil) but they do not speak to us in Ixil and they scold us…” Comadrona (TBA)

Preliminary Results: Survey Data

Number Percent

Houses visited as part of the census

1590 100%

Eligible households for survey (child <5)

754 47.4%

Ineligible households 588 37%

Vacant: 148; absent: 87; refused : 11

94% self-identified as indigenous; 6% non-indigenous

19% gave birth to their last child in a facility; majority give birth with comadronas (TBAs)

Survey Data

• Questions for measuring disrespect & abuse and respect promoting practices were based on:

– Disrespectful & Abusive Maternity Care Framework

– Disrespect and abuse studies in East Africa

– Formative research in Ixil

– Guatemala’s guidelines/norms for culturally appropriate care

(Disrespect/Abuse)Bribe

NeglectNon-consent

Neg. gestures/comment

(Respect Promoting)Language

Birth CompanionChose Position

Preferred clothing

D&A/RMC Questions

• Survey included two sets of similar disrespect and abuse questions for women who had a home birth & women who had a facility birth– Facility birth cohort: asked about their own experiences– Home birth cohort: asked about perceptions/beliefs

about facility births

• This allows for comparison between self-reported experiences and beliefs/perceptions

D&A: Facility Cohort

At any time during your stay at facility “X” did they do something to you that made you feel bad?

Answer n frequency CI

Yes, they did something to me 10 6.9 2.7 11.1

No, they did not do something to me 134 93.1 88.9 97.3

Total 144 100

“Global” disrespect and abuse question (facility cohort) indicates 7% prevalence

Results: comparison of

experiences vs.

perceptions

D&A Item (% reported "yes") facility cohort(n=144)

home cohort(n=598)

Neglect 12% (17) 9% (51)

Pay/give something for better care 6% (9) 9% (51)

Negative body language/comments 4% (6) n/a

Non-consent 9% (13) n/a

Spoken to in one's language 65% (94) 45% (268)

Had a birth companion 59% (85) 40% (238)

Chose one's birth position 19% (28) 24% (138)

Use of preferred clothing 63% (91) 20% (119)

Contribution• Testing the construct of D&A in a Latin America context

(rural, hard-to-reach)

– What components of the D&A construct are relevant; missing in context of rural Guatemala

– What are the contributors to and consequences of experiencing and perceiving D&A in this context?

• Consider relationship between D&A and ‘respect-promoting’ practices

• Contribute to measurement lessons: training local data collectors, adapting tool in a local language; data collection in remote areas; measurement as an intervention

Acknowledgments• TRAction Guatemala team

based at the URC office in Guatemala, Hernán Delgado (PI)

• Implementing partner COTONEB & CHWs

• Field supervisors Miguel Brito and Elena Gómez

• Data collection teams from Ixil

• The families from the 15 communities who shared their time and experiences with us.