Plain english summary
Background
Overview of intervention tested at facility level
Goal: To promote Respectful Maternity Care | ||||||
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Expected out comes; Reduce incidents of D & A; improve provers attitude and work environment | ||||||
Intervention areas | Priority focus on forms of D&A | Proportion or number of participants reacheda
| Duration | Periodicity during the intervention | Indicator/measurements (baseline and endline results)
| |
b. |
Training of providers on strategies that improve provider attitude
-Training of providers using value clarifications and attitude transformation change approach (VCAT) | All forms of D&A | 90% (n = 132) managers trained on RMC across all project sites 62% (n = 146) providers trained in project 13 sites ranging from 7 to 45 of providers in maternity units | 2 days 3 days | One provider and one manager workshop per county Quarterly - Two to three on site mentorship sessions per sites |
-% of providers who report improved attitude as a result of the intervention
|
c.
|
Psycho-social support for health care providers
-Providing groups and individual counselling session for providers -establish psycho-social support structures between facilities and communities | All forms of D&A | 49% (n = 113) providers (8–12 per site) 77% (n = 10) facilities with functional referral mechanisms for psycho-social support structures in project sites
| 45 min- 1 h | Quarterly |
-% of facilities that have continuous counselling sessions for providers
|
d. |
Maternity Open Days
| All forms of D&A | 100–300 persons (depends on facility size and location) | 24 (total) for 1 day All study sites conducted at least one session Ranged from 1 to 4 session per facility and reached | Quarterly | -% of facilities that conduct maternity open days at least once every quarter - % of provider reporting improved client provider interaction -% of clients who have correct knowledge on birthing process and procedures |
e
|
Establishment of multi-disciplinary peer support groups/ watch dogs
| All forms of D&A | 53% (n = 13) of facilities with functional peer support groups in facility catchment sites -Instances where any cases of D & A are discussed and amicably resolved | 7 out of 13 facilities established multi-disciplinary peer support groups/watch dogs | Quarterly | -% of D&A cases reported and amicably resolved |
Methods
Study design
Data sources and collection
Baseline | End line | ||||
---|---|---|---|---|---|
Category of participants | Methods | Type of respondents | Number of participants | Type of respondents | Number of participants |
Policy makers | In depth Interviews | Policy makers in health and program civil society leaders, health rights advocates at national and county level | 23 | County Health managers | 10 |
Health providers | In depth Interviews | Facility managers, Maternity ward or unit in charges | 56 | Facility managers, Maternity ward or unit in charges | 23 |
Quantitative Structured interviews | 49 first line services providers in maternity units and 18 managers interviewed for IDIs | 67 | 69 first line services providers in maternity units and 6 managers interviewed for IDIs | 75 |
Data management and analysis
Qualitative data analysis
Quantitative data analysis
Measure | Items |
---|---|
Client rights (0–14 items) | Informing/orienting the clients of her where about in the facility/ ward/unit; Explaining clients when and how procedures will be performed and the outcomes; Obtaining consent for all procedures to be done; Informing client of danger signs during labour and delivery and after birth; Informing her of the labour progress and expected possible duration of labour; Allowing her to choose her birthing position; Allowing her to choose a birth partner/companion during labour and delivery; Respecting her privacy; Keeping her information confidential; Ensuring privacy and confidentiality at all time while attending to client during labour and delivery; Respecting her as an individual with her own rights despite her background; Ensuring that the procedures are promptly done within the required guidelines; Ensuring that the mothers labour is monitored using a partograph; Taking client to theatre for caesarean section when is not really necessary. |
Client-centered care (0–7 items) | I feel that it is always necessary to obtain consent from clients when conducting a vaginal examination; If a woman’s uterus rupture during labour and delivery and it becomes necessary for the doctor to perform hysterectomy in order to save her life - It is always necessary to inform her of this unplanned procedure before she is discharged home; On admission mothers should be allowed to select the provider/s of their choice during labour and delivery; Mothers who are unable to pay for maternity services should not be detained in the facility to avoid losing the much needed revenue; Treating mothers with care and respect during child birth does make clients come back to this facility; During labor and delivery not being harsh to the mothers ensures that they cooperated with you during procedures; Sharing of beds in this facility is generally not acceptable to the mothers during labour and delivery. |
HIV Care (0–7 items) | I do not try to avoid conducting vaginal exam for HIV positive clients; I am comfortable conducting a delivery for a client who is HIV positive; I am comfortable repairing a tear or an episiotomy for a HIV positive client; I do not feel that during labour and delivery the HIV positive client should be isolated from the rest; I am comfortable caring for mother who has HIV soon after delivery; I am comfortable nursing babies born of mother who are HIV positive; Recording clients positive HIV status on the clients card/mother baby booklet make some of the clients uncomfortable. |
Emotional health (0–22 items) | Not emotionally drained from my work; Not used up at the end of the workday; Not fatigued or tired when they get up in the morning and have to face another day on the job; Easily understand how their patients feel about things; Do not treat any patients as if they were impersonal objects; Working with people all day is not really a strain for me; Deal very effectively with the problems of their patients; Not burned-out from my work; Positively influence other people’s lives; Have not become more callous/hardened toward people since I took this job; The job is not hardening them emotionally; Very energetic; Not frustrated by my job; I do not feel I’m working too hard on my job; Really care what happens to all patients; Working directly with people does not put too much stress on me; Easily create a relaxed atmosphere with their patients; Accomplish many worthwhile things in this job; Exhilarated after working closely with their patients; Do not feel like they are at the end of my rope; Deal with emotional problems very calmly; Patients do not blame them for any of their problems. |
Management (0–14 items) | Job decisions are made by my manager in an unbiased manner; My manager makes sure that all staff concerns are heard before job decisions are made; To make job decisions, my manager collects accurate and complete information; My manager clarifies decisions and provides additional information when requested by staff; All job decisions are applied consistently across all affected staff; Staff are allowed to challenge or appeal job decisions made by my manager; My manager offers adequate justification for decisions made about my job; When making decisions …my manager treats me with kindness and consideration, …my manager treats me with respect and dignity, …my manager is sensitive to my personal needs, …my manager deals with me in a truthful manner, …my manager shows concern for my rights as an employee, …my manager discusses implications of the decisions with me, …my manager offers explanations that make sense to me. |
Job fairness (0–5 items) | My work schedule is fair; I think that my level of pay is fair; I consider my workload to be quite fair; Overall the rewards I receive here are quite fair; I feel that my job responsibilities are fair; |
Supervision (0–5 items) | I think this is a fair supervision system; I feel good about this supervision system; I am satisfied with this supervision system; The feedback I receive is fair; I think my supervisors are knowledgeable for effective supervision |
Promotion (0–5 items) | I think this is a fair promotion system; I feel good about this promotion system; I am satisfied with this promotion system; The promotion opportunities I have are fair; Compared to other people doing similar work, my opportunities for promotion are fair. |
Health system (0–9 items) | I think this is a fair system; I feel good about this system; I am satisfied with this system; This system provides fair training opportunities; The outcome of this system is that I get the training I deserve; I am adequately trained for the tasks I perform; Most of the training I have received has improved or changed how I practice; The training I have received in general has been of high quality; The facility management has offered me an opportunity to practice post in-service training. |
Work environment (0–13 items) | Enough staff to provide quality patient care; Enough staff to get the work done; Opportunity to work on a highly specialized patient care unit; Adequate support services allow health workers to spend time with patients; Freedom to make important patient care and work decisions; Patient care assignments that support continuity of care, i.e., the same health workers care for the patient from one day to next; Health professionals control their own practice; Adequate pre-service education for my current position; Adequate clinical practical opportunities during pre-service training; Adequate opportunities for professional development and career; Adequate clinical supervision in this service; Consistent availability of supplies and medications to perform my duties; Functioning equipment and infrastructure to perform my duties. |
Working relationships (0–14 items) | Enough time and opportunity to discuss patient care problems with other staff; A manager who is provides support supervision and leadership; A manager who backs up the staff in decision-making and conflict resolution even if the conflict is within cadre, below or with a more qualified member of staff; Hospital/clinic managers support and value health workers; Doctors, nurses and other health workers have good working relationships; Medical Officers have good working relationships with Clinical Officers; Nurses have good working relationships with Clinical Officers; Medical officers have good working relationships with Nurse midwives; Obstetricians have good working relationship with midwives; Enrolled nurses have good relationships with registered nurses; Nurses have good relationships with Medical Officers/interns; Nurses have good relationships with doctors; Collaboration (joint practice) between different cadres of health workers; A lot of team work between different cadres of health workers. |
Results
Characteristics of providers
Characteristics | Baseline (n = 67) % (n) | End line (n = 75) % (n) |
p – value |
---|---|---|---|
Facility type | |||
Hospital | 91.0 (61) | 90.0 (63) | 0.920 |
Health center | 6.0 (4) | 5.7 (4) | |
Maternity home | 3.0 (2) | 4.3 (3) | |
Type of sector | |||
Government/council | 76.1 (51) | 77.1 (54) | 0.888 |
Private or faith based | 23.9 (16) | 22.9 (16) | |
Gender of provider | |||
Female | 82.1 (55) | 77.5 (55) | 0.500 |
Male | 17.9 (12) | 22.5 (16) | |
Current working station of provider interviewed | |||
Admission room | 1.6 (1) | 10.3 (7) | <.0001 |
Antenatal room/ward | 15.9 (10) | 17.7 (12) | |
Post-natal ward | 14.3 (9) | 16.2 (11) | |
Nursery | 0 (0) | 2.9 (2) | |
Serving in all areas | 0 (0) | 38.2 (26) | |
Labour/Maternity ward | 58.7 (37) | 14.7 (10) | |
Other | 7.9 (5) | 0 (0) | |
Background | |||
Doctor/Clinical Officer/Med Intern | 13.4 (9) | 6.7 (5) | 0.211 |
Nurse/Midwife | 86.6 (58) | 85.3 (64) |
Understanding and operationalization of client’s rights
Baseline (n = 67) Mean score (SD) | End line (n = 75) Mean score (SD) |
p - value | Cronbach’s alpha | |
---|---|---|---|---|
Clients Rights (0–14) | 4.5 (2.4) | 6.2 (3.1) | 0.001 | 0.70 |
Emotional Health (0–22) | 16.3 (3.4) | 14.8 (3.6) | 0.036 | 0.76 |
Client Centred Care (0–7) | 1.8 (1.4) | 5.6 (1.3) | <.0001 | 0.80 |
HIV care (0–7) | 1.5 (1.5) | 4.8 (1.9) | <.0001 | 0.81 |
“As we think how to reduce D&A, at the very least train providers on the clients’ rights and obligations” (Manager, Baseline)
“You know in our set up the client is always right so if they say I don’t want to be in this position or I do not want to stand here for long then you explain to the client the risks and benefits then the client makes the decision. ” (Maternity in-charge, endline)
“Because we are short in staffing, we want a quick eye contact both sides of the ward….when you are running to attend to the other cases there, I can be able to spot this mother in bed five very fast … the staffing does not allow us to have good ample one-on-one personalized care … I would not want them to be under the curtain because if she is changing conditions there while am busy doing other things, by the time I realize, things are worse.” (Midwife, endline)
Providers’ work related environment
Emotional health
Baseline (n = 67) % (n) | End line (n = 75) % (n) |
p – value | |
---|---|---|---|
Client Rights (14 items) | |||
Informing/orienting the clients of her where about in the facility/ward/unit | 41.8 (28) | 56.5 (39) | 0.086 |
Explaining clients when and how procedures will be performed and the out comes | 38.8 (26) | 63.2 (43) | 0.005 |
Obtaining consent for all procedures to be done | 50.8 (34) | 65.2 (45) | 0.087 |
Informing client of danger signs during labour and delivery and after birth | 29.9 (20) | 24.6 (17) | 0.495 |
Informing her of the labour progress and expected possible duration of labour | 32.8 (22) | 43.5 (30) | 0.202 |
Allowing her to choose her birthing position | 27.3 (18) | 18.8 (13) | 0.244 |
Allowing her to choose a birth partner/companion during labour and delivery | 17.9 (12) | 24.6 (17) | 0.338 |
Respecting her privacy | 62.7 (42) | 81.2 (56) | 0.016 |
Keeping her information confidential | 37.3 (25) | 65.2 (45) | 0.001 |
Ensuring privacy and confidentiality at all time while attending to client during labour and delivery | 40.3 (27) | 52.2 (36) | 0.165 |
Respecting her as an individual with her own rights despite her background | 25.4 (17) | 44.9 (31) | 0.017 |
Ensuring that the procedures are promptly done within the required guidelines | 29.9(20) | 37.7 (26) | 0.335 |
Ensuring that the mothers labour is monitored using a partograph | 25.4 (17) | 37.7 (26) | 0.123 |
Taking client to theatre for caesarean section when is not really necessary | 3.0 (2) | 7.3 (5) | 0.261 |
At endline one respondent said;“…In the same place... they are very active (referring to midwives)...you can find somebody who has worked overnight and yet is still in the mood of working. That one we can give a locum (extra work for pay) and maybe there is one who cannot handle the work after such a shift.... she is so stressed... but I can you tell both are tired anyway but we do not have enough staffs……we need someone to cover a shift” (Maternity Manager. baseline).
“…Sometimes nurses experience burnout related to work and workload and sometimes related to outcomes like a maternal death. And it would put them in a situation where they are not able to cope” (Midwife, Endline)
Perceptions on supervision, job fairness and management
“Women expect too much from the providers, if the provider does not have curtains or blankets, they can do nothing to ensure comfort and privacy” (Midwife, baseline).
Qualitative data further show improvements in provider perceptions of manager-provider interactions. Stakeholders as well as baseline results suggest need for an intervention focusing on managers’ leadership roles and responsibility for improving maternity units’ working conditions.“So even if she would appreciate the value and clarification exercise, she is not able to deliver fully to the client as she would also wish to do … the human resource factor is a problem. The other handicap was the space, the infrastructure in itself.” (Medical doctor, endline).
Managers at endline were described as supportive of both clients and providers engaging in RMC-promoting behaviors. A nurse manager described her role in sustaining Heshima practices.“Some maternity managers can be trained in leadership and the management should select competent managers in those positions, focus should also be on facility in charges themselves… provide equipment also” (Facility Manager, baseline).
Results also show improved provider management, communication, and teamwork, resulting in better relations between providers and clients.“We are adhering to what we learnt about respecting our clients…. we are encouraging men to come for ANC where we encourage mothers to come with their spouses… we want them to feel comfortable; we give them a visit round the facility so that in the event they come [for delivery] they know where they will be attended and by who. We are also encouraging the staff to be courteous to the clients…to introduce themselves …make sure they have their name tags properly displayed…” (Facility manager, endline).
However, managers – and providers who experience heavy workloads – express frustration with the effort required to ensure clients receive quality and respectful care. One manager lamented about her inability to address understaffing, which may contribute to client rights’ violations.“The element of communication really improved; midwives could communicate very well with clients and it reduced some of clients’ perceptions of disrespect and abuse … another thing which worked very well was teamwork, which started at the site of implementation; the maternity itself, the nursing office... right to the Health Management Team.” (Nurse-midwife & mentorship coordinator, endline)
Providers also reported that the promotion system is unfair, pay inadequate, and demotivating. Provider demotivation across Kenya may have stemmed from three nationwide providers’ strikes that lasted five out of the 20 months of the study’s implementation period, for reasons that included delayed salaries, poor pay, lack of promotion, and poor working conditions. Some providers suggest rewarding good behavior and attitudes to motivate providers offering maternity care services. “They [providers] should be motivated in a way, even if it’s not allowances or cash but the management or professional should appreciate the unique work that is being carried out at the maternity… we can rate the health provider in the maternity who is doing well … maybe the best appreciated midwife can be recognized and given trophy, something like that.” (Facility in-charge, endline).“I make the best noise I can to my in-charge to improve staffing in maternity…. And she also raises her hands up (implying giving up) that I have also made noise up there (implying to staffing office) and there have not posted for me staff…. So you will work with what you have. But I will not keep quiet but it is the reality. You want to give the quality care… but it needs the manpower to give it”. (Reproductive health coordinator, endline)