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Around the world, disrespect by health care providers during childbirth violates principles of privacy, dignity, equality, and autonomy. Providing respectful maternity care (RMC) can encourage mothers to deliver at health care facilities and improve health outcomes.
In Ethiopia, common forms of mistreatment of mothers delivering in health facilities include culturally inappropriate care, a lack of curtains or other visual barriers to protect privacy, and failure to obtain consent before procedures. Our project team aimed to increase RMC in facilities participating in a quality improvement collaborative. Interventions included videos of women sharing their experiences with disrespect during delivery and childbirth, skill building sessions on communication, and coaching by partners and district leaders.
To encourage empathy and connection with their professional obligations, our team asked providers questions after watching the videos: “How did you feel about the video?” and “How would you feel if the women in the video were your mom, sister, or wife?”
One provider said:
“I used to deny providing information because I felt the women did not understand it. I did not even consider it’s [a woman’s] right to get adequate information. After the video, my attitude changed. I am convinced that they need to get adequate information [for] their level of understanding during labor and childbirth. I feel this is one of the ways to respect women during and after childbirth.”
Participants coming to the training reviewed the project baseline assessment. This included interviews with women about their experience in delivery. The team identified gaps in care based on these interviews and the scenarios in the testimonial video. They then developed change ideas by using fishbone (cause and effect) diagrams and the five whys approach to identify the root causes of disrespectful maternity care.
These change ideas included: maintain privacy, make space for a birth companion, maintain cleanliness, safely reduce waiting time, and improve skilled deliveries. High-impact change ideas to apply in their respective facilities were selected based on a prioritization matrix, available resources, time, and conditions.
We were able to get leadership buy-in to implement and test changes. The project ran trainings for leaders. We presented the status (baseline data) before beginning project testing and implementation. We conducted quarterly review meetings so facilities could review their work and enhance their learning.
Women who received care from the facilities were engaged as community representatives to reflect on the health service quality. Responding to community-raised concerns during a community conference — a gathering of community members to hear their thoughts about services and discuss identified service delivery gaps — helped boost leadership support. We also provided training for maternal and child health staff on clinical skills and the Compassionate, Respectful, and Caring (CRC) approach to communication with the clients.
The facilities’ services improved after this work. Rates of providing privacy and allowing birth companions increased significantly and were sustained beyond the project period. We were surprised and happy that improvements were seen very quickly due to the will of the professionals, despite not having many resources. For example, health care workers’ perceptions about women’s rights changed. Before this improvement work, health workers did not understand the need to respect the culture and beliefs of their clients during labor and childbirth.
We faced challenges with resources, supplies, and training. Infrastructure issues included rooms too small to allow space for a birth companion, big rooms with multiple women and no privacy, and a lack of curtains, screens, and labor bars. Facilities have high workloads and struggle to fill charts, maintain privacy, and allow birth companions.
To address these challenges, we provide onsite orientation sessions run by QI coaches. We worked with the facility regulations management team to discuss the available budget and purchase necessary supplies. We also looked for other partners to work with to fill the resource gap.
We aimed to create a continuous quality improvement culture and planned follow-up coaching visits. Leadership engagement on quality improvement work has supported teams to introduce, implement, and sustain adequate levels of change. Facilities undergo quarterly assessments of patient experience and satisfaction. Patient satisfaction survey findings from the Ethiopian Hospital Services Transformation Guidelines (EHSTG) were embedded into the system. Teams engaged in strategic advocacy to teach policymakers about client-centered care. To support learning, teams worked on measurements of RMC elements, including greeting patients, introducing themselves, explaining procedures, encouraging patients to ask questions, and responding to questions politely.
For others doing this kind of work, I would suggest the following:
- Build QI skills. Some components of RMC — including reducing wait times to provide dignified care, for example — go beyond provider attitudes and require quality improvement skills. Integrating this project into an existing woreda- (district-) wide QI collaborative was important.
- Involve leadership. Leaders were engaged during the training. The project also facilitated separate meetings for leaders to review their facilities’ work.
- Empower patients. Gathering community member feedback about the maternity service was very helpful.
- Work with what you have. Despite limited resources, the facilities were able to test and sustain changes.
Our work suggests that integrating respectful maternity care into QI training brings a positive impact for health care staff and patients. As more women are comfortable seeking care and get the care they need, this care can save lives.
Mehiret Abate is a Senior Project Officer at IHI.
You may also be interested in:
The QI Essentials Toolkit: Maternal Health and other maternal health resources