Respectful Maternity Care: Evidence from East and Southern Africa Eva Bazant, Reena Sethi, Ephrem Daniel Jhpiego Monitoring, Evaluation and Research USAID Mini University, Washington, DC March 2, 2015
Respectful Maternity Care:
Evidence from East and Southern Africa
Eva Bazant, Reena Sethi, Ephrem Daniel
Jhpiego Monitoring, Evaluation and Research
USAID Mini University, Washington, DC
March 2, 2015
Session Outline
� Introduction to respectful maternity care (RMC)
and disrespect and abuse (D&A)
� Findings of RMC and D&A in Malawi
� Findings of RMC and D&A in Ethiopia in an
evaluation of a quality improvement approach
� Pilot to measure RMC through SMS in Kenya
� Q&A and discussion
Introduction
Landscape Analysis
� Extensively reviewed literature on disrespect and
abuse (D&A) in facility-based childbirth: 7 categories
� Explored contributors to D&A at levels of: individual
and community, laws and policies, governance and
leadership, service delivery and providers
� Explored the impact
� Reviewed interventions to promote respectful care
� Identified gaps in evidence: prevalence, consistent
definitions, validated tools, impact studies
Source: Bowser and Hill (2010). Exploring Evidence for Disrespect and
Abuse in Facility-based Childbirth: Report of a Landscape Analysis. USAID
TRAction Project. Harvard and URC. www.tractionproject.org
Source: White Ribbon Alliance. 2011. Respectful
Maternity Care: The Universal Rights of Childbearing
Women. Washington, DC: WRA.
Barriers to Facility-Based Delivery
Include D&A
Source: Bohren MA, Hunter EC, Munthe-Kaas HM, Souza JP, Vogel JP,
Gulmezoglu AM. 2014. Facilitators and barriers to facility-based delivery
in low- and middle-income countries: A qualitative evidence synthesis.
Reproductive Health 11:71.
� Medicalization of childbirth
� Previous birth experiences
� Cost of childbirth
� Perceived quality of care at facilities
� Stigma
� Methods:
� 34 qualitative studies reviewed from 17
LMICs, CerQual approach to assess findings
The World Health Organization Calls for:
� Support from governments for research and
action to generate data related to respectful and
disrespectful practices
� Programs to improve quality of care and RMC
� Emphasis on women’s rights to dignified,
respectful health care throughout pregnancy
and childbirth
� Systems of accountability and professional
support
� Involvement of all stakeholders, incl. womenSource: WHO. 2014. The prevention and elimination of disrespect and
abuse during facility-based childbirth. Geneva: WHO. Accessed at:
www.who.int/reproductivehealth/topics/maternal_perinatal/statement-
childbirth/en/
Defining D&A: AMDD
1. At Policy level
� Deviations from international human rights
standards and national standards of quality of
care
2. At Structural level
� System deficiencies and D&A identified as D&A
(or not) by women, by providers
3. At Individual level
� Normalized D&A (by women or by providers)
� What all agree/admit is D&A
Source: Freedman L et al. 2014. Defining disrespect and abuse of
women in childbirth: A research, policy and rights agenda.
Bulletin of the World Health Organization 92:915–917.
Prevalence of D&A: Two Studies
Tanzania Nigeria
L&D client exit
interview
Home interview
at 6 weeks
Postnatal ~
immunization
interview
D&A Type n=1,779 n=593 n=446
% % %
1. Non-consented care <1 <1 55
2. Physical abuse 3 5 36
3. Non-dignified care 13 19 30
4. Abandonment/neglect of care 9 16 29
5. Non-confidential care 4 6 26
6. Detention in health facility <1 <1 22
Inappropriate demands for payment 2 3
7. Discrimination 20
Any D&A experienced 19 28 98
Kruk et al. 2014. Disrespectful and abusivetreatment during facility delivery in Tanzania: A facility and community survey. Health Policy Planning. doi: 10.1093/heapol/czu079
8 facilities, different
types
Okafor et al (2015). IJGO 1 teaching hospital
Measurement of D&A Prevalence
May Vary Based on:
� Method/sources of data:
� Interview with women (at facility at L&D
discharge, home later
on, postnatal or
immunization)
� Observations of care (external, internal, who)
� Provider interview
� Samples: How obtained,
size, location, service area
� Instrument: Items, any
validation, response
categories,
scales/indexes
� Confidentiality: To
women and providers
� Context: Type and
number of health
facilities, client
volume, staffing,
fees/costs
MCHIP Quality of Care Studies
Measured . . .
� Policy-level: Main focus is on national and
WHO standards* for quality of care for
normal L&D and complications www.mchip.net/QoCSurveys
� Structural-level: Health facility inventory
� Individual-level: Provider performance
during provider-client interactions and care
� D&A items were added later
*Source: World Health Organization. 2006. Pregnancy, Childbirth, Postpartum and
Newborn Care: A Guide for Essential Practice, Integrated Management of
Pregnancy and Childbirth (IMPAC) Toolkit. Geneva, Switzerland: WHO.
Generating Postpartum SMS Client Feedback to
Improve Respectful Maternity Care:
A Pilot Study in Kenya in 2015
Background
� Concerns with client exit interviews:
� In Tanzania, women’s reports of D&A increased
between the exit interview and an interview 6
weeks later in the home (Kruk et al. 2014)
� Responding to the survey while not at the facility
may help with validity, but can lead to lower
response rate
� Studies collecting data on paper forms may
be slow to feed the findings back to the
facilities for quality improvement
Mobile Phone Use is High in Kenya
30,732,000 mobile
phones in a
population of
45,010,056
(CIA World Fact Book, 2014)
Pilot Project Objectives
� Assess the acceptability of a mobile SMS
platform for an RMC-focused survey of labor
and delivery clients (percentage of women
reporting respectful or disrespectful care
and high satisfaction)
� Assess the feasibility of facilities to respond to
aggregated client feedback for quality
improvement
Areas of Work
� Kiambu
� Kisumu
� Kitui
� Makueni
� Meru
� Migori
9 District HospitalsWe expect to enroll 400
women at L&D discharge
Seeking to Provide a . . .
SMS Questions (Illustrative)
� How was the . . . � Respect the providers showed?
� Kindness of the providers?
� Cleanliness at this facility?
� Did you receive any hot tea or food?
� Was . . .� Your privacy respected?
� Your information kept confidential?
� Were the provider’s findings explained?
� Was your choice of birth position respected?
� Were you shouted at, scolded, or insulted?
� Were you attended to during labor or childbirth?
Questions?
THANK YOU