Date Published: July 11, 2017
Publisher: Public Library of Science
Author(s): Stephanie A. Kujawski, Lynn P. Freedman, Kate Ramsey, Godfrey Mbaruku, Selemani Mbuyita, Wema Moyo, Margaret E. Kruk, Mark Tomlinson
Abstract: BackgroundAbusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women’s poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania.Methods and findingsWe used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21–0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05–0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19–0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings.ConclusionsAfter implementation of the combined intervention, the likelihood of women’s reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project’s facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486.Trial registrationISRCTN Registry, ISRCTN 48258486
Partial Text: Maternal health in the Millennium Development Goal (MDG) era (2000 through 2015) was dominated by a focus on increasing skilled birth attendance, typically through facility delivery, as a means to reducing maternal mortality . Countries with high maternal mortality ratios (MMR) worked to remove barriers to delivery in health facilities by eliminating user fees, providing conditional cash transfers, improving transport, and scaling up emergency obstetric care [2,3]. In sub-Saharan Africa, the MMR dropped by 45% between 1990 and 2015, which was short of the 75% MDG target, and the region still accounts for 66% of all maternal deaths as of 2015 .
The study protocol was approved by the IRBs of Columbia University, Ifakara Health Institute, and the National Institute for Medical Research in Tanzania.
At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). Women did not participate in the study largely due to the required wait time postdischarge for the administration of the interview. At baseline, there were some statistical differences between women delivering in the intervention hospital versus the comparison hospital (Table 2). A higher proportion of participants in the intervention facility than the comparison facility were married and of higher socioeconomic status, and a smaller proportion reported low mood or depression in the last 12 months or ever being physically abused or raped. Higher proportions of participants in the comparison facility had shorter lengths of stay for delivery and were more likely to come directly to the facility for delivery compared to women in the intervention facility. Other baseline characteristics were not statistically different. Preintervention trends in the main outcome between the 2 facilities did not differ significantly, with the exception of the first month of data collection, which was likely due to a small sample of surveys collected in that month.
This study found that after a participatory community-health system intervention in Tanga Region, Tanzania, the likelihood of self-reported disrespectful and abusive care during labor and delivery was significantly reduced (66% reduced odds). The largest reduction was for physical abuse, followed by neglect. Process indicators showing better patient-reported quality of care in the intervention facility, including respectful treatment from providers, support the likelihood that the intervention was responsible for the reduction in disrespect and abuse. Importantly, these effects were still observed nearly one year after the end of Staha’s facilitation of implementation in the intervention district, indicating the potential for sustainability.
This study provides evidence that a participatory community-health system intervention that articulates new norms, standards, and practices for mutual respect between patients and providers and supports their implementation through facility-based management and health provider reflection is a potential strategy to reduce the prevalence of disrespect and abuse during childbirth. The magnitude of the effects observed here suggests that this is a promising direction for future efforts to reduce disrespect and abuse. Future initiatives to build on the Staha findings should carefully adapt the intervention to local context, retain the active participation of key stakeholders, and explore efficient means for scaling it both geographically and institutionally by identifying the particular changes needed at higher levels of the health system to sustain such practices at the frontline [39,40].