Twenty-eight individuals were interviewed, including 20 “influencers” and eight “influenced.” The influencers came from research and academia, health professional organizations, non-governmental organizations, government and donor agencies, human rights law, program implementation, and advocacy. The influenced individuals represented six countries and worked in the fields of research and academia, health professional organizations, non-governmental organizations, and government organizations. Data from the interviews informed the refinement and validation of the framework for awareness raising.
Primary results: Validated framework for awareness raising
The final, validated framework for raising awareness includes five strategies that characterize a successful awareness-raising effort.
1.
The effort utilizes elements of strategic planning
2.
The effort aims to capture the attention of key stakeholders
3.
The effort delivers a consistent persuasive message
4.
The effort creates a receptive environment
5.
The effort maximizes all existing and potential resources
Within each strategy is a set of tactics—framed as actions—that can operationalize the strategy. The resulting 20 tactics are organized into three groups based on the proportion of key informants who described using a component in their work: integral (reported by 80% or more influencers), helpful (reported by 50–79% of influencers), and variable (reported by fewer than 50% of influencers). See Table
3 below.
Table 3
Validated awareness-raising framework
...utilizes elements of strategic planning. |
Clearly define your position on the topic | .90 | X | | |
Clearly define your end goal or objectives | .75 | | X | |
Constantly assess and adapt to the environment and context in which you are working | .95 | X | | |
...aims to capture the attention of key stakeholders. |
Clearly define the target audience | .95 | X | | |
Identify and pay attention to the different levels of influence (take a multi-level approach to identifying and approaching the target audience)* | .65 | | X | |
Use communication channels that are appropriate given your target audience’s preferences and behaviors | .90 | X | | |
Find ways to stand out and be noticeable | .25 | | | X |
...delivers a consistent, persuasive message. |
Ensure that your message is delivered by a credible messenger and uses credible sources | .95 | X | | |
Ensure that your message is clear | .90 | X | | |
Ensure that your message aligns with the target audience’s prior knowledge and the current context | .85 | X | | |
Establish a shared, consistent language/lexicon, particularly when working with a loose coalition* | .70 | | X | |
Ensure that the message is informative | .75 | | X | |
Use your message and tactics to lead the target audience’s attention to your topic | .50 | | X | |
Leverage the norms that guide your target audience’s behaviors | .80 | X | | |
Leverage the target audience’s values and preferences and find ways to change or shift those | .80 | X | | |
Select a consistent and appealing theme or tone for your message | .85 | X | | |
Ensure that the audience is exposed to the message sufficiently for it to sink in | .40 | | | X |
...creates a receptive environment. |
Leverage the problems and pressures that govern the audience’s behavior(s) | .85 | X | | |
Involve the audience in your efforts to develop or spread the message | .60 | | X | |
Use multiple channels to reach the audience | .85 | X | | |
...maximizes all existing and potential resources. |
Coordinate with like-minded partners (individuals and organizations) | 1.0 | X | | |
Identify your internal and external human and financial resources and allocate them wisely | 1.0 | X | | |
Leverage individuals’ passion for the topic especially when the work is largely unfunded* | .70 | | X | |
Overall, 14 of the 20 elements in the draft framework were used by 80% or more of the influencers and can thus be considered integral to create a successful awareness-raising effort as they were constant across nearly all influencers regardless of setting, context, goal, or resource capacity. Of those 14 elements, eight were used by 90% or more of the influencers. For example, 90% (n = 18) of the influencers reported outlining a clearly defined position on RMC. Among those, the positions (of both individuals and organizations) fell into three categories: RMC as a human right, RMC as a quality of care issue, and RMC as a behavioral norm. A constant awareness of the current environment and willingness to adapt the effort and message accordingly was also integral (reported by 95% of influencers). Researchers and advocates took into account the existing legal, political, medical-cultural, and system factors/norms that might influence their audience’s beliefs and behaviors around pregnancy or childbirth. For example, one influencer working in Latin America explained that, “It was a favorable context [for RMC] in Bolivia, Ecuador, and Mexico. There was a strong consolidation of women’s groups and good media coverage of women’s/indigenous rights, and constitutional frameworks. It was a context in which there was accountability and awareness of the duty bearer’s responsibility.” Context shaped the way the influencers approached their work, and often, changes to goals or positions were in response to changes in the environment. Several respondents used the term “evolved” or “evolving” to describe the environment and context as well as their approach to promoting RMC.
Nearly all of the influencers (95%, n = 19) stated that they had a clearly defined target audience. Although not all influencers were concerned with the same audiences, the influencers reported targeting pregnant women, indigenous women’s groups, consumer groups, medical and midwifery students and practitioners, doulas, health care facility administrators, local parliamentarians, lawyers, academics, researchers, donors, and international development agencies. Some influencers focused on one audience while others found ways to reach multiple groups: one influencer explained, “[as an organization we] were trying to target maternity services worldwide. But as an obstetrician, I have been targeting medical education in personal work; with both medical students and qualified doctors as well as NHS midwives to make them aware of human rights in childbirth, respectful maternity care, and obstetric violence.” Influencers also reported using appropriate (i.e., relevant to the target audience’s information-consumption habits) communication channels (90%, n = 18) and employing credible messengers and sources (95%, n = 19) to share a clear message (90%, n = 18). “Using appropriate channels” meant attending and presenting at key maternal health technical meetings and human rights fora for some, or for others, creating posters on D&A/RMC and distributing them to health facilities. Credible messengers included leaders in maternal health from donor agencies (e.g. USAID), academia and research (e.g. AMDD), and professional organizations (e.g. IMBCO, DONA International).
For most of the influencers, the messages used were closely tied to each organization’s or individual’s position and centered on the basic concepts of human rights, respect for women (and providers), respect for culture and the variety of experience, and quality of care. The messages also differed slightly depending on the target audience in order to make the message as appealing as possible. As one influencer explained, “Because [our organization] works at so many levels (global, country-level and national and subnational levels) we strategically target our RMC messaging to specific audiences, using messages that we think will resonate with distinct stakeholders: [for example, we focus on] professional ethics for provider professional associations, human rights for women’s groups, increasing institutional delivery for policymakers, quality of care for Ministry of Health stakeholders, providers and clients, etc.” Another influencer working in research and implementation noted that her organization “had three levels of messages: policy level … health facility, and the community.”
Importantly, this research evaluated awareness-raising efforts that extended beyond traditional message dissemination. Because few of the influencers were engaged in formal communications campaigns, other actions such as funding programs or conducting research related to RMC conveyed the message that RMC was a priority. All influencers also reported identifying and strategically allocating human, financial, and material resources (100%, n = 20). Finally, all influencers reported partnering with other likeminded individuals and organizations (100%, n = 20), highlighting the importance of partnerships for successful awareness raising. As one influencer from an international development agency explained, “Coming from a health system perspective and structural perspective, when thinking about things that are non-health but that still affect health, you begin to put together a network [of organizations]. Nothing that’s important to be done can be done by a single group. You can’t change policy or be proactive alone, much less sustain those changes over time. We all need to be good colleagues and think about large ecological frameworks. Thinking about continuity is important, and partnerships are a part of that.”
Four of the 20 elements from the draft framework were used by 50–79% of respondents and can be considered “helpful” when creating and executing an awareness-raising effort. Defining an end goal or objectives (75%, n = 15), creating an informative (70%, n = 14) and attention-getting (50%, n = 10) message, and involving the target audience in the effort to raise awareness (60%, n = 12) were all helpful tactics for influencers. Participants described various ways in which they involved the target audience. One influencer videotaped providers during a birth and played it back for them so that they could see their own behavior—both respectful and disrespectful—firsthand. Another influencer described creating opportunities for dialogues between women and health providers “so they can exchange ideas about good practices … best practices” related to RMC.
Three additional elements—not included in the original draft framework—were identified through thematic analysis and fall into the “helpful” group: 1) identify and pay attention to the different levels of influence in maternity care (described further below); 2) use a shared, consistent lexicon around D&A/RMC; and 3) leverage individuals’ passion for RMC and human rights to support work when funding is low or nonexistent.
Sixty-five percent (n = 13) of the influencers noted that they identified and took into consideration the different levels of influence affecting maternity care when planning their work. These levels of influence include individual care providers, pregnant women, facility administrators, national decision makers, and global influencers, such as the World Health Organization (WHO). For example, one influencer explained that, “a big part for us is articulating a comprehensive strategy with different elements and targets—at the policy systems level, point of care with providers, and rights and demand perspective from women themselves.” On the other hand, an influencer whose work focused on research and facility-level solutions remarked that theirs was, “a very multipronged approach to look at whatever seemed to be a driver [of disrespect and abuse] in the facility.”
Seventy percent (n = 14) of respondents expressed the importance of having a shared language or lexicon regarding D&A/RMC among all of the different organizations and individuals acting as influencers; by using the agreed-upon term “respectful maternity care,” influencers felt they could support and complement, rather than distract from, the work being done by partners and other likeminded advocates. One influencer noted that, “as the debate [about D&A] has become more refined, there’s been more clarity. ‘Respectful maternity care’ is a good way of framing it. And that became a catch phrase, or a good hook for what’s fundamentally a moral and ethical orientation.” Another influencer highlighted the importance of using the term consistently: “We developed our measurement [of D&A] based on Bowser and Hill’s work, but since [the WHO] paper on different groupings of mistreatment, we’re using that. And … we won’t stop calling it [respectful maternity care] now, because the movement is there.”
A passionate commitment to RMC, high-quality care, and women’s rights were identified as central to the effort to raise awareness of D&A/RMC. More than half of the influencers (n = 14) described themselves or their colleagues as “volunteers,” all driven by the same commitment to RMC and women’s health and rights in general. One influencer described herself and her network of colleagues working on RMC as “a coalition of the willing.” Another influencer explained: “We’re also part of what is a growing movement where we interact with many people with no expectation of money changing hands or formal engagement. We’re just working toward a shared goal.”
Finally, two of the 20 elements from the draft framework were used by fewer than half of the respondents and thus can be considered “variable.” One quarter of influencers reported that they tried to find ways to stand out and be noticeable; for example, one influencer cited a promotional book tour that provided an opportunity to meet with women and speak about respectful maternity care. While only 40% (n = 8) of influencers reported that they made an effort to expose the audience sufficiently to their message, such efforts may have been captured in another component of the framework (see “use multiple channels”).