Applying a participatory approach to the promotion of a culture of respect during childbirth

Generating an open dialogue on disrespect and abuse in a healthcare setting can be
challenging. Healthcare administrators, providers, and women seeking care are understandably
apprehensive about identifying incidence of DA within their facility. In an effort
to assuage any potential uneasiness towards conducting research around this sensitive
area, the study team strategically engaged with key influencers at the facility, district
and national levels of the health care system throughout the course of the project.
These stakeholders included influential policymakers within the Ministry of Health
and Social Welfare who had expressed support for this work in prior conversations
with the study team, and leaders of the district-level Council Health Management Team
responsible for the facility. We also engaged with key members of the study facility,
i.e., nurses and midwives on the frontline of providing antenatal care services and
influential members of hospital staff including the matron in-charge, head of obstetrics
and gynecology, nurse in-charge of the maternity ward, and the Director of Programs.
We posit that the multilevel support generated through our participatory implementation
process amplified the effect of the discrete interventions, reinforced the principles
of respectful maternity care 3], and had a positive influence on the outcomes observed. Similar to prominent efforts
aimed at reducing HIV stigmatization, including programs targeting the prevention
of vertical HIV transmission during pregnancy 4], identifying DA during childbirth at the facility as an issue to be “corrected”
and conducting a highly visible project were interventions in and of themselves.

Sensitization

At the project’s initiation, a series of sensitization meetings were held with policymakers
at the Tanzanian Ministry of Health and Social Welfare (MOHSW); the municipal medical
officer of health; the Council Health Management Team (CHMT); and hospital administrators
and health care providers in the maternity departments of the study hospital. These
consultations focused on creating awareness of DA and generating support to further
explore the issue from key maternal health stakeholders at the national, regional
and municipal levels. We also consulted with members of the Staha study team, who
at this time had initiated a similar study in the Tanga Region of Tanzania 5]. Our ability to engage the MOHSW and increase awareness of DA was greatly facilitated
by this complementary work.

Participatory dissemination

In the first phase of the project, a baseline assessment found high levels of disrespect
and abuse, both as reported by women and as directly observed by trained data collectors
6]. After the baseline assessment was completed, we conducted a three-step participatory
dissemination process, the goal of which was to create a culture of transparency,
collaboration, and institutional accountability and responsibility. Baseline results
were presented initially to the hospital management team and then to providers at
the study facility to allow them to internalize and reflect on the findings without
assigning blame or attributing fault to specific individuals or areas of the hospital.
The second dissemination meeting included hospital providers as well as district-level
officials, and focused on receiving input about the feasibility, desirability, and
sustainability of potential evidence-based interventions developed from an extensive
literature review 7]. After the second consultation, a technical working group—comprised of maternity
ward healthcare providers, hospital management representatives, municipal-level health
managers, representatives from local and international partner organizations, and
study team members—was formed to continue developing interventions that were deemed
applicable and appropriate for the study facility. Finally, results were disseminated
nationally to obtain feedback and generate high-level consensus on intervention selection.
Participants included national representatives from the Ministry of Health; leaders
from the regional and municipal health offices; maternal health experts from development
partners; academics from medical and nursing institutions; representatives from medical
and nursing professional associations; and health care providers and management from
the study hospital.

Women who shared their experiences of disrespect and abuse during baseline data collection
did not participate in the dissemination process. The decision to limit the audience
to those working in the health system was based on the recommendations and requests
from key influencers in the region. The rationale was that the initial identification
and targeted reduction of DA needed to be provider-led to allow for acceptability,
cooperation, and receptivity of facility-level interventions. Sensitivity around the
issue of DA and tenuous patient-provider relationships—as evidenced by the baseline
findings—could have escalated into disagreements and blaming exercises, and negated
efforts to mitigate DA during childbirth.

Intervention selection

Based on this multi-level participatory process, two interventions were selected:
Open Birth Days (OBD) and Respectful Maternity Care Workshops. Open Birth Days included
a participatory health education session and tour of the study facility and were open
to all women attending antenatal care at the facility during their third trimester.
The sessions were designed to improve women’s comfort with the facility and increase
birth preparedness by facilitating communication with providers and providing a step-by-step
guide to what to expect when they arrive at the facility for delivery. The Respectful
Maternity Care Workshop consisted of six modules adapted from the Health Workers for
Change curriculum 8]. The goals of the Workshop—which was facilitated by seasoned trainers and respected
medical school professors—were for providers to reexamine how their current practice
matches their professional codes of conduct, reflect on the needs and preferences
of patients, and openly and honestly discuss the barriers that prevent the provision
of RMC at the study facility. At the conclusion of the workshop, participants decided
upon an action plan that could be carried out of their own accord with minimal influx
of external resources. Steps taken by the facility through this action plan included
improved use of privacy curtains, changes to staffing structure, and improvements
in the speed of overtime payments, among others.

Rollout of the selected interventions began in April 2014 and continued through October
2014. Reflecting the success of the participatory selection process, nurses in the
antenatal ward at the facility began OBD in December 2013 immediately after the national
dissemination meeting using their own time, resources, and ideas to drive implementation.
Beginning in April, these processes were standardized for implementation and evaluation,
and the significant support from facility staff continued throughout the implementation
period. The accompanying research article describes in detail the complete implementation
and evaluation protocol, and provides evidence from routine monitoring and evaluation
activities of marked progress towards achieving proximal and intermediary outcomes
targeted under the project’s theory of change (Fig. 1) 1]. In total, 362 women participated in the Open Birth Days Sessions (100 % acceptance
rate) and 76 staff from the maternity ward participated in the RMC Workshop (86 %
participation rate). Evidence from multiple monitoring tools shows that, over the
course of the intervention, there were improvements in both proximal and distal outcomes
including: patient knowledge of their rights and birth preparedness, provider knowledge
of patient rights, provider attitudes, provider job satisfaction, and patient-provider
communications and interactions. Additionally there is evidence that patients were
more empowered after participation in an Open Birth Day session, and patient satisfaction
with their delivery experience improved substantially from baseline (75.8 % very satisfied
compared to 12.9 % at baseline).

Fig. 1. Theory of Change