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