Respectful Maternity Care implementation research in Tanzania: The Staha Project GWU Miliken School of Public Health June 24, 2014.

Respectful Maternity Care implementation research in Tanzania: The Staha Project

GWU Miliken School of Public Health

June 24, 2014

AIM:REDUCE D&A

medicine and supplies stockouts

community doesn’t know their rights

health workers don’t know their rights

distrust between providers and

clients

health worker burnout &

demotivationlack of safe channels

to report D&A

organizational culture in the health system

provocation by relatives

modeling of D&A behaviours in training

unfair processe

s in the health

systemweak

accountabilityPOWER

DYNAMICS

discrepancy between policy promises and reality

lack of recognition for good performance

infrastructure weaknesses

workforce shortages

stress of maternity assignment

ethics

Pre-intervention qualitative data: Patient-provider interactions• Misunderstandings about what is the health workers’ fault

and what is due to system constraints • Community distrust health workers, think that they steal

medicines and sell in their own pharmacies• Health providers distrust community, think that they don’t

understand what actually happened/are ignorant• Good interactions exist outside the work environment (as

neighbors or at social events), but changes at facility• Nurses are typically blamed• Neither patients nor providers feel that they know their rights

Values driven process:

Mutuality of respect

Patients

Respectful Health System Environment

Providers RESPECT

Participatory planningPreliminary

results, identification

of root causes,

brainstorm solutions

Stakeholders across levels:• National• Regional• District • Facility• Community

Propose and review potential solutions

Community members

Village and ward leaders

Health workers in

the maternity

District and facility

management

Represent-atives

from local groups

Community members

Health workers in

the maternity

Staha Change Process• Client Service Charter

– Adapt the national charter in a participatory process at district and health facility level to elaborate the value of mutual respect

• Facility-based quality improvement– maternity teams address issues related to mutual respect and

devise ways to implement and measure change

• Community and health system management actions– Communities implement and monitor activities to support providers

and ensure accountability– District leaders and managers change practices to support an

environment of respect and attention for providers and patients

District and facility

management policy and practice changes

Facility-based QI

process to change

environment/ practice

Community-driven

actions to support and

monitor system

District-level

adaptation of charter

Facility- level

adaptation of charter

Norms and

standards of mutual respect

Increased mutual respect

Consensus building on norms and standards

Multi-level activation of mutual respect norms Improved outcomes

Increased facility-based

deliveryReduced D&A

during childbirth

STAHA CHANGE PROCESS

Implementation research:data collection methodsCharter QI processQualitative interviews/FGDs Maternity exit surveyDrafting meeting minutes Provider weekly surveyParticipant observation Weekly observationCharter feedback forms Collective efficacy surveyDissemination/activity monitoring forms*

QI team weekly meeting minutesQualitative interviews/FGDs

Implementation research strategy

• Based on:– Damschroder et al’s Consolidated Framework for Advancing

Implementation Science (CFIR)– Carroll et al’s Framework for Implementation Fidelity

• Overall goal of studying and uncovering the process of the implementation under key domains:– Moderators of change– Support mechanisms– Context and inner/outer settings– Fidelity

Intervention components

Client Service Charter• National charter developed in 2005, never adapted

at district levels• Korogwe is the first district to adapt charter to

reflect local needs and concerns• District charter developed first, followed by facility-

specific charters• Mechanism to open dialogue between different

levels of district health system and communities

Steps in local charter adaptationAt district & facility levels:• Select charter committee• Review MoHSW/existing charter• Develop new draft of charter• Solicit feedback from multiple stakeholders

through comment forms & community meetings• Integrate comments in charter• Seek approval by District Council• Disseminate, implement & monitor• Make revisions as needed

Frequent Comments on Draft• More transparency of fees

and services• Services should be

provided in a timely manner• Make providers’ rights more

specific• Facilities should be a

corruption-free environment • Use respectful language

when speaking to patients

Key messages in the charter• Mutuality of respect• Patient rights & responsibilities• Provider rights & responsibilities• Standards of service, including relationships• Standards of ethical conduct• Accountability, feedback and complaint

mechanisms• Equality and respect for all• Ongoing maintenance of charter

Dissemination and Activation

• Materials developed to support dissemination– Printed copies of charters– Summaries of key provider and patient rights and

responsibilities– Posters

• Meetings with key leaders at district, health facility and community levels– Training on dissemination of charter – Plans and commitments for charter activation

Quality Improvement Process

• Views disrespect and abuse as a systemic problem rather than an individual or behavioral problem

• Applies a clinical quality improvement framework to an interpersonal quality of care issue (adapts Institute of Healthcare Improvement framework)

Intervention launch at Magunga Hospital, Korogwe District• 2-day workshop to introduce QI to the maternity ward and

key personnel from RCH, theatre, and pharmacy• Staff identified drivers of D&A and proposed specific

interventions for change• 6 people chosen by their peers as the QI team:

– 1 doctor from the maternity ward– 2 nurses from the maternity ward– 1 pharmacist– 1 nurse from RCH– 1 nurse from theatre

• The regional MOH QI specialist and the deputy medical officer in charge at the hospital supervised the team

Quality Improvement Interventions

• Move admission and discharge to a private room• Obtain/use curtains in the delivery room and

screens in the maternity for privacy• Pharmacy creates a stock out list each week to post

in the maternity ward• Recognize providers with tea, certificates, etc.• Peer-to-peer learning with Bombo Hospital QI Team

QI Intervention: Implementation research• Self-reported exit survey of all postpartum women on

quality of care and satisfaction with interaction with providers

Provider knowledgeLanguage useProvider communicationProvider responsiveness Overall quality of care

RespectPrivacyAvailability of drugs and suppliesWard cleanliness

Patient surveys: analysis

• N = 1720, 43 weeks of data from August 2013-April 2014 (ongoing)

• Two weeks of baseline data collection• Data divided into pre-post intervention at week 19

– All interventions implemented by week 15– At week 19, providers started to use a checklist per

patient to ensure that interventions were followed

Patient surveys: logistic regression analysis• Outcome categorized as excellent vs. other

categories• Main predictor: pre/post 19 weeks• Controlled for age and clustered on date

Patient surveys: results to questions (%)

Excellent Good Fair Poor

Overall quality of care 70.01 27.24 2.58 0.18Respect 70.30 27.83 1.76 0.12Privacy 68.13 28.66 3.22 0.06Language use 65.33 31.55 3.06 0.06Provider communication 66.86 31.07 1.83 0.24Availability of supplies 70.35 26.13 2.94 0.59Provider knowledge 73.72 24.10 2.06 0.12Ward cleanliness 65.44 30.99 3.04 0.53

Patient surveys: results to questions by time period (%)

< 19 weeks ≥ 19 weeks

Excellent Good Fair Poor Excellent Good Fair Poor

Overall quality of care

63.34 32.69 3.69 0.27 75.00 23.16 1.74 0.10Respect 61.39 35.61 2.73 0.27 77.00 21.97 1.03 0.10Privacy 62.79 32.28 4.79 0.14 72.13 25.92 1.95 0.00Language use 58.07 37.24 4.55 0.14 70.73 27.33 1.94 0.00Provider communication 60.64 36.58 2.23 0.56 71.44 27.02 1.54 0.00Availability of supplies 62.17 32.87 4.26 0.69 76.43 21.11 1.95 0.51Provider knowledge 70.66 27.27 1.79 0.28 76.00 21.74 2.26 0.00Ward cleanliness

58.45 37.60 3.27 0.68 70.70 26.02 2.87 0.41

Overall quality of care.4

.5.6

.7.8

% r

atin

g a

s e

xce

llent

0 10 20 30 40Weeks

Week 3: Admission/discharge moved Week 8: Curtains for delivery cubicles Week 10: Screens in maternity ward for exams Week 15: Posting of supplies/drugs available Week 19: Checklist of interventions

Respect.4

.5.6

.7.8

.9%

ra

ting

as e

xcelle

nt

0 10 20 30 40Weeks


Privacy.5

.6.7

.8.9

% r

ating

as e

xcelle

nt

0 10 20 30 40Weeks


Provider language.4

.5.6

.7.8

.9%

ra

ting

as e

xcelle

nt

0 10 20 30 40Weeks


Provider communication.4

.5.6

.7.8

% r

ating

as e

xcelle

nt

0 10 20 30 40Weeks


Availability of supplies


.4.5

.6.7

.8.9

% r

ating

as e

xcelle

nt

0 10 20 30 40Weeks

Provider knowledge


.5.6

.7.8

.9%

ra

ting

as e

xcelle

nt

0 10 20 30 40Weeks

Ward cleanliness.4

.5.6

.7.8

.9%

ra

ting

as e

xcelle

nt

0 10 20 30 40Weeks


Other events in maternity ward: example – overall quality of care

.4.5

.6.7

.8%

ra

ting

as

exce

llent

0 10 20 30 40Weeks


Week 18: nursing students start

Weeks 27-29: staff shortage

Week 24: nurse changes

Patient surveys: regression results

Outcome Odds Ratio

95% CI

Overall quality of care 1.59*** 1.20-2.13

Respect 1.95*** 1.47-2.58

Privacy 1.40* 1.08-1.82

Language use 1.61*** 1.24-2.09

Provider communication 1.45** 1.12-1.87

Availability of supplies 1.93*** 1.45-2.56

Provider knowledge 1.16 0.87-1.54

Ward cleanliness 1.45** 1.10-1.91

P-value: *<0.05, **<0.01, ***<0.001

Challenges to implementation • Interventions that require funds or approval by hospital

management can take longer to implement• Maternity ward staff who did not attend the QI training were

less able to explain the process and its importance• Documentation/monitoring of interventions can be difficult

due to poor record-keeping at the maternity ward • Some women express concern when using moveable

screens in the maternity ward that being covered during examination implies serious illness

Limitations of findings

• Preliminary results not adjusted for time trends• Trend could be due to something other than

intervention (ex: availability of supplies)• Positivity effect: women could be rating everything

as positive overall• Women have changed over time?• No comparison group

Implications for future Staha research• End line survey to see if intervention is having an

effect on D&A

Thank you

Moderators of change: key questions• How have key stakeholders contributed to the

implementation/intervention? • How did participants of the intervention react to and

accept the intervention? • How has the perception of disrespect and abuse

changed over time?• What is the role of the health providers’ collective

efficacy in facilitating change?• How have the power dynamics between patients and

providers changed?

Moderators of change: data components• Charter process:

– Personal narration by charter facilitator– In-depth interviews with key stakeholders– Participant observations

• QI process:– In-depth interviews with key stakeholders– FGDs with health providers– Patient exit survey– Provider survey– Provider collective efficacy survey

Support mechanisms

• Key question:– To what extent did the Staha team itself affect the

outcome of the intervention? For example, what occurred/may not have occurred without the support and facilitation of the implementers/researchers?

• Data component:– Project documents– Qualitative interviews

Fidelity• Key questions:

– To what extent is the intervention being implemented as intended?

– What were the challenges to implementation? What elements of the intervention were adapted during the implementation in order to react to the realities on the ground?

• Data components:– Project documents, meeting minutes– Qualitative interviews with key stakeholders and participants– Observations

Context: inner/outer settings

• Key question:– How do the social, economic, structural, and political

factors of the intervention district, including of the targeted intervention community and of the health facilities, affect the implementation and the intervention outcome?

• Data components:– Qualitative interviews with key stakeholders– Landscape scanning

Charter Process: Preliminary lessons• Charter committee representation from district government and health

system and community• D&A in childbirth as lens onto broader quality issues – touches on

many encounters with the health system• Building consensus

– Allow space for airing contentious issues– Gradual consensus building from disparate perspectives

• System insiders open to new possibilities; recognize value of community perspectives

• Community representatives made aware of structural/capacity limitations; recognize their own power to make change

• Local government leaders start recognize their role in ensuring quality of health services for their populations

Respectful Maternity Care implementation research in Tanzania: The Staha Project GWU Miliken School of Public Health June 24, 2014.

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