Background
Methodology
Study context
Data sources
Heshima objectives: |
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1. Determine the manifestations, types and prevalence of disrespect and abuse in childbirth; |
2. Develop and validate tools for assessing disrespect and abuse; |
3. Identify and explore the potential drivers of disrespect and abuse; |
4. Design, implement, monitor, and evaluate the impact of one or more interventions to reduce disrespect and abuse; and |
5. Document and assess the dynamics of implementing interventions to reduce disrespect and abuse and generate lessons for replication at scale |
Data Sources | Study groups | Timing and sample |
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In-Depth Interviews (IDIs) | District health program managers/coordinators | Baseline (n = 56) |
Health care providers (nurses, doctors) | ||
Facility in-charges (nurse-midwives/matrons) | Supplemental data (n = 33) | |
Community health workers | ||
Traditional birth attendants | ||
Policy makers (county-level) | Endline (n = 33) | |
Professional associations (nursing, medical) | ||
Women who delivered at a facility in the last 6 months | ||
Focus Group Discussions (FGDs) | Community members: | Baseline (n = 20) |
Single and multi-parity women (separate groups) | Supplemental | |
Men in the community | data (n = 8) | |
Opinion leaders (chiefs, elders) | Endline (n = 5) | |
Case Narratives | Women who delivered at a facility in the last 6 months | Baseline (n = 51) |
Endline (n = 14) | ||
Process Documentation | Community dialogue report | Feb 2012 |
National Stakeholder Forum report | March 2012 | |
Trip reports from comprehensive supervision visits | (n = 6) | |
FIDA/ The Nurse/Midwife Association report(s) to | (n = 10 each) | |
PC (quarterly). Steering committee meeting notes | (n = 12) | |
Donor reports(quarterly /annual) | (n = 15) |
Analytical approach
Results
Stakeholders | Role | Level of Influence | |
---|---|---|---|
Heshima Project Members | Population Council (The Council) | Led the consortium, designed the research, coordinated intervention. Long-term presence in Kenya (since 1960s). Respected by MOH (both as an institution - evidence for policy and individual staff). Engaged MOH prior to and during proposal development. Institutional knowledge existing maternal health research /evidence; Member of national technical working groups, support national policy, strategy and guidelines development. Rights-based approach to reproductive health services. | High |
Federation of Women’s Lawyers - FIDA | Promotes women’s rights through advocacy | Medium | |
Build on work on meditation for inheritance, land disputes and documenting abuses to women. | |||
Contributed to policy and community component | |||
National Nurses Association of Kenya- Midwifery Chapter | Empower health providers to provide quality care | Medium | |
Support health facility interventions: training in values clarification and attitude transformation, quality improvement teams, supervision with MOH | |||
Steering Committee | Kenya Obstetric/ Gynecological Society. University of Nairobi: Depts: Nursing, ObGyn. School of Public Health; WHO, UNICEF, MOH-Dept. of Nursing, Division of Reproductive Health, Nursing Council of Kenya | Policy level mechanism to provide feedback on study design and implementation process | Medium (as a group) |
Review /develop study instruments and design and monitoring of intervention | |||
MOH/public sector | MOH headquarters | Director of Public Health launched/supported project. Director of Medical Services committed throughout. | Medium |
Nursing Council of Kenya | Semi-autonomous institution - legislative responsibility for Nursing/ midwifery training curriculum and examining board. Introduced revised regulatory standards, scope of practice and ethical code in 2013 | High | |
Dept. of Nursing | Technical support /design of intervention/supervision | Medium | |
Division of Reproductive Health | Technical support and policy guidance: participated in IR process, design and monitoring of intervention | High | |
Department of Human Resources | Project results used to support health sector reforms to address drivers of mistreatment including provider accountability | Low | |
County health management teams | Oversee policy implementation provide direction for implementation and monitoring result utilization. | Medium | |
Facility/maternity unit managers | Oversee policy implementation and provide supportive environment for frontline providers and community | Medium –High | |
Service providers: nurses doctors, midwives | Beneficiaries of training/Implement interventions | High | |
Parliamentarians | Advocacy | Low | |
Media | Advocacy | Medium | |
International NGOs | Reproductive health/ MNH partners: Jhpiego, IPAS, FCI, FHI360 | Contributed to development of RMC resource package (training guide for facilitators, participants and communities) and advocacy. | Medium |
Community | Community health extension workers | Linkage between facility and community. Oversee and train CHVs facilitate alternative dispute resolution | Medium |
Community health volunteers/Legal aid officers | Sensitize communities on universal rights, obligations for childbearing women and other rights issues. | Medium | |
Sensitize how to demand for health rights and report incidents of mistreatment and help coordinate alternative resolution meetings | |||
Community members | Perceptions of disrespect and abuse, awareness of rights at baseline and endline beneficiaries | Low | |
Women | Perceptions of men extent of male involvement and how to support women | ||
Men | |||
Mothers who have delivered in facilities | Perceptions and experiences at baseline and endline | Low | |
Private sector/ Faith based Institutions | Civil society organizations CSOs: | Participate in policy discussions and dissemination | Low |
Private /faith based providers | Implementers of intervention | ||
Reproductive Health Rights Alliance | Steering committee member | Low | |
Development partners | USAID /Washington and Kenya | Funded Heshima through TRAction Project (USAID/W) steering committee member (USAID Kenya) | Medium |
UNICEF - Kenya | Steering committee member | Low | |
WHO –Kenya | Steering committee member | Low |
Implementation process
Intervention Activity | Purpose | Participants | Frequency | Duration | Location | |
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Policy level | ||||||
1. | Project Launch | High level MOH officials launched Heshima. Media invited. Participants invited to Project Steering Committee to guide/monitor activities. | 80 | One time | One morning | Nairobi |
2. | Project Steering Committee | Maternal health champions known to Heshima with mandate to support quality childbirth met routinely to review project progress | See Table 4
| 12 | Half day | Nairobi |
3. | Global Policy Review | Desk review of international conventions, treaties, signed by Kenya, national laws, and the new constitution for relevant policies and guidelines on human and childbearing rights for promoting and strategizing for RMC by The Council and FIDA. | FIDA lead | One time | 20 days | Nairobi |
4. | Baseline questionnaire development training of data collectors | Formative research conducted to understand the context and mistreatment terminology by communities and provider motivation and accountability issues prior baseline questionnaire development. Health managers from national nursing and reproductive health units were invited to be part of the data collector training. Specifically requested to coordinate observations of client provider interactions during labor and delivery in the 13 study facilities. | Heshima and steering committee Heshima (Council led), MOH, data collectors | Ad hoc meetings | 30 days | Nairobi & non- study site |
One time | 1 week | Nairobi | ||||
5. | Community Dialogue and National Stakeholder Forum | Community level findings disseminated in each facility catchment area Stakeholders: community, facility, national, global representatives. Baseline findings – drivers of disrespect and abuse (See Fig. 2) – disseminated then group work by level and county to suggest interventions to mitigate disrespect and abuse. | 1996 community members 100 stakeholders | One time | 1 day | Nairobi |
6. | Participatory Intervention Development | Meetings with Heshima members and Steering Committee to review discussions from No.5. | 20 | Series of meetings | 1 month | Nairobi |
7. | Development of RMC Resources and Curricula | 1) Baseline results and stakeholder consensus on the content of training materials; 2) Values components adapted from IPAS training materials; 3) Sessions on rights based approach, service charter including accountability. 4) Added professional code of ethics. 5) MOH convened national meetings on RMC curricula development for both pre- and in-service training; 6) Final face to face meeting with project partners and steering committee members refined the RMC resource package; and 7) Two international experts reviewed final version prior to completion. RMC components were incorporated into national curriculum. | 10–15 national maternal health stakeholders 7 members Nursing Council of Kenya | 3 meetings plus virtual experts in training material development | 7 days 30 days | Nairobi |
8. | National Policy Dialogue and Development | Policy engagement through the national reproductive health interagency coordination committee, technical working groups for maternal and newborn health, Human Resource and monitoring and evaluation. Presentations of results to get buy in prior to national dissemination. Meetings continued for scale up plans. | 20–40 stakeholders /meeting | 4–8 meetings (quarterly) | half day | Nairobi |
The Council participated in small expert meetings (invitees only) to draft Maternal Health Bill and ensure disrespect and abuse during facility based childbirth incorporated. | 10–15 national stakeholders | 15 meetings | Half day /meetings | Nairobi | ||
Working with the high level policy makers such as Kenya Women’s Parliamentary Association, the Parliamentary Health Committee and the first Lady to advocate for Reproductive /Maternal Health Rights. | Over 50 | 3 strategic meetings Plus ongoing | Half day meetings | Nairobi | ||
9. | Advocacy | National conferences and meetings with media (e. g. Kenya Media Network), researchers, professional associations (midwifery, ObGyn and medical) and policy makers on health rights and promoting RMC. Continuous advocacy by MOH and Heshima. | 120 national stakeholders | 12 targeted meetings. | Half day national meetings | Nairobi / county level |
Health system - Facility level | ||||||
10. | VCAT Workshops | RMC workshop (1–2 days) for county health managers, facility and maternity in charges, i.e. those who supervise /support frontline providers Three day workshop for facility staff. Each of the study facilities developed action plans to institutionalize RMC in maternity units. | 132 146 Maternity providers | One time /county Facility reps to one meeting | 2 -day workshop 3- days /workshop | All study Counties and facilities |
11. | Mentorship | Following VCAT workshops, on-the-job role-modeling for provider behavior change by facility champions as part of routine continuous professional development. | 13 identified, 4 actively engaged | Conducted as part of routine work | continuous on job session | 4 sites: 2 public, 2 private |
12. | Quality Improvements teams | Strengthened facility management and quality improvement teams to monitor, address, and resolve incidents of mistreatment. Address infrastructure, drugs and commodity supply concerns. Quality improvement teams trained on rights and obligations related to childbirth, developed protocol for reporting and monitoring, and encouraged community membership. Established mechanisms for transparency and accountability of health facilities to communities, increase awareness of maternal healthcare rights. | Public facilities −10; private facilities −0) 3–6 members | Quarterly review meetings 4 x year | Ongoing and 2–3 h meeting | All study counties |
13 | Counseling for providers | Counseling for providers at the group and/or individual levels to support providers with coping mechanisms to overcome experiences related to high workload, trauma or critical incidents. Conducted by FIDA counselors (one counseling session per site) and role modelled sessions with the facility or county counsellors. Counselors continued with counseling sessions in their respective sites. | 113 providers (8–12/ site) | 26 sessions; 9 sites one each. 4 sites; 3–4. | 45 min- 1 h per session | All study counties |
14 | Maternity Open Days | Trust-building with local communities: men and women visit the facility to learn about procedures in the maternity wards and interact with staff. | 100–300 depends on facility size | 24 (total) | 1 day each | All study counties |
15 | Monitoring of disrespect and abuse | Provided mechanisms to report incidents of disrespect and abuse such as customer service desks, suggestion boxes and through Heshima/MOH supervision. County health teams and facility quality improvement teams conducted monitoring and supervision as part of their routine work. | ~350 community members ~35 at facilities | 17 county visits 22 community health units; 13 facility visits** | ½ day community health units and ½ day facility | All study counties |
Community level | ||||||
16 | Community workshops | One day workshop held for community resource persons (community health volunteers, legal aids, chiefs, religious leaders/village elders) on civic education of community rights to sexual and reproductive health including maternal health care. FIDA facilitated the workshop. CHEWs support community health volunteers to develop action plans. | 154 community people trained | 5 times (1 per county) | 1 day each workshop | Catchment of all facilities |
17. | Community education and male involvement | Community health volunteers, CHEWs, opinion leaders, civil and legal aids) conducted RMC sensitization meetings for community members with support from county mangers. Deliberate efforts were made to involve men in the community workshops as participants and facilitators. Targeted meetings for men: ‘calling them to action’ to demand RMC for their wives and partners. | 1996 people: 287 male only, 871 female only, 838 mixed groups | 27 meetings | Half day | Catchment areas from around facilities |
18. | Mediation training for society leaders | Trained society leaders (e. g. CHVs), on mediation skills, to act as intermediaries between community members and health facility to address issues of disrespect and abuse. Mediators selected by communities and facilities (on set criteria) and trained by FIDA. *** Counseling community members who have experienced mistreatment. Led by FIDA and other professional counselors. Referrals from CHVs or community legal aids. | 22 from community health units, 13 from facilities 2 out of 6 women | 5 times (1 per county) Twice | 1 day per session 1 h per session | All study counties One site |