Measuring prevalence of D&A
during childbirth in Tanzania:
The Staha Project
Respectful Maternity Care seminar
GWU Miliken School of Public Health
June 24, 2014
The task
• The landscape analysis CATEGORIZED types of D&A
reported in the literature.
• The definition must provide the CRITERIA that an incident
or condition must meet in order to qualify as D&A.
2
The definition should:
• Capture structural D&A as well as individual D&A
• Enable multiple disciplines (e.g., law, human rights, public
health) to use their tools to address D&A
• Enable measurement of D&A
• Do no harm. Definitions shape the narrative and
“appropriate” the experience of D&A
3
Building blocks for defining D&A
• A list of observable actions/behaviors, some of which
are context specific
• Actions that are experienced as disrespectful or
abusive
• Intentional infliction of pain or emotional distress or
humiliation, either by commission or omission
• Facility conditions and clinical treatment that do not
meet accepted/consensus standards found in the
human rights documents, national law, policies
(AAAQ).
4
Defining disrespect and abuse in facility-based childbirth
Structural level:
System deficiencies that lead to
poor care that is accepted and
normalized
Individual level
Structural level
Policy Level
Deviations from national
standards of good quality care
Deviations from human rights
standards (available, accessible,
acceptable, quality)
Policy Advocacy
Structural level:
What women and providers
consider poor care, but is caused
by system deficiencies
Prevalence Measure
Individual level:
Normalized D&A:
What women experience as D&A
but providers consider normal
When providers are disrespectful
and abusive but women consider
it normal
Initial intervention target
Individual level:
actions that all agree are D&A
Study setting – Tanga Region
Tanga region,
Tanzania
population: 2,010,480*
* 2011 estimate by the National Bureau of Statistics based on the 2002 Population and Housing Census
Study setting:
Korogwe and Muheza, Tanga
Korogwe:
intervention
Muheza:
comparison
population: 341,166*
population: 324,000*
4 Sites:
District hospital
3 health centers
* 2011 estimate by the National Bureau of Statistics based on the 2002 Population and Housing Census
4 Sites:
District hospital
2 health centers
1 dispensary
Facility exit interviews (N=1,779)
• Women approached after
discharge from 8 study facilities
• Interviewed in tents outside of
the facility for privacy and
convenience
• Response rate: 71%
Advantages
• Can obtain a large sample in
a limited amount of time
• Reduces potential for recall bias
• Cost-effective
8
Community follow-up interviews (N=593)
• Subset of women from facility exit interview sample
• Interviewed 5-10 weeks postpartum in their homes
• Interviewed about D&A, health seeking behaviors,
postpartum depression
• Response rate: 76%
Advantages
• Provides an environment where women may feel
more secure to share their experiences
• Allows women more time to reflect on their
experience/adjust to newborn
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How were women asked about D&A?
A) Single question: asked the following question before any
specific D&A questions were asked
At any point during your stay for this delivery, were you treated in
a way that made you feel disrespected or abused?
B) Experience of D&A events
Now we’re going to read you a list of things that sometimes
happen to women who have given birth in a facility. For each of
these things, please tell me if you have experienced it during
your recent delivery at this facility. Please keep in mind we are
talking about this delivery and not your past deliveries.
Example:
Health providers threatening to withhold treatment because
patient could not pay or did not have supplies.
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D&A categories and events in questionnaire
NON-DIGNIFIED
CARE
•
•
•
•
Shouting at/scolding patient
Threaten to withhold treatment
Negative comments to patient
Threatening comments to patient
NEGLECT
• Ignoring patients requests for assistance
• No attendant at delivery
PHYSICAL
ABUSE
•Hitting/slapping/pushing/pinching, etc.
•Rape
•Sexual abuse
• Stitching of episiotomy without anesthesia
NONCONFIDENTIAL
CARE
NONCONSENTED
CARE
INAPPROPRIATE
DEMANDS FOR
PAYMENT
•Discuss patient’s private health information in public
•Share patient’s health information
•Patient’s body seen by others
•Tubal ligation, caesarean or hysterectomy without consent
•Request bribes/informal payments
•Mother or baby held at the facility due to failure to pay
11
Facility exit vs. community follow-up:
prevalence of D&A by experience
8.7%
Shouting/scolding
13.2%
7.9%
Ignored when needed help
14.2%
5.3%
Threatening or neg comments
11.5%
4.2%
Threat of withholding treatment
6.0%
4.4%
Lack of physical privacy
6.2%
3.9%
Delivery without attendant
5.3%
2.7%
Physical abuse
5.1%
1.8%
Request for bribe
3.1%
Rape
Detention for failure to pay
Sexual harrassment
Tubal ligation w/o consent
Hysterectomy w/o consent
C-section w/o consent
0%
Facility Exit (N=1,761)
5%
10%
15%
Community Follow-up (N=592)
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Maternity ward observations (N=310)
• Women observed from active labor to 2 hours
postpartum at 2 hospitals
• Capture observable events of D&A and their context
using same list of events as on facility
exit/community follow-up questionnaire
• Same women are then interviewed on exit by a
different person
• 77% of women who were observed participated in
the exit survey
13
Observation vs. facility exit: prevalence of
D&A by experience
6.3%
Shouting/scolding
45.5%
3.8%
Ignored when needed help
19.7%
2.9%
Threatening or neg comments
45.2%
2.3%
Threat of withholding treatment
5.5%
1.3%
Lack of physical privacy
9.1%
Delivery without attendant
0.8%
Physical abuse
0.8%
3.2%
12.9%
0.8%
1.6%
Request for bribe
Rape
Detention for failure to pay
Sexual harrassment
Tubal ligation w/o consent
Hysterectomy w/o consent
C-section w/o consent
0%
5%
10%
15%
Facility Exit (n=240)
20%
25%
30%
35%
40%
45%
50%
Observation (N=310)
14
D&A prevalence measures
Self-report
single item
D&A
• binary measure (yes or no)
• based upon single question in
interviews
Self-report
any D&A
• binary measure (any or none)
• based upon women reporting
experience of at least one or
more of 14 events
Observed any
D&A
• binary measure (any or none)
• based upon observation of at
least one or more of 14 events
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D&A measures
Facility
Community
Self-report
single item
(n=1,779)
Self-report
any D&A
(n=1,761)
Self-report
single item
(n=593)
Self-report
any D&A
(n=592)
Observed
any D&A
(n=310)
Self-report
single item
(n=240)
Self-report
any D&A
(n=240)
16
D&A measures by source
Self-report
single item
(n=1,779)
Facility
6.3%
Self-report
any D&A
(n=1,761)
19.5%
4.2%
Self-report
single item
(n=240)
Observed
any D&A
(n=310)
Self-report
any D&A
(n=240)
71.3%
10%
Community
Self-report
single item
(n=593)
12.7%
Self-report
any D&A
(n=592)
28.2%
17
Complexity of Care Environment
Same nurses
who observed
70% any D&A
Observations of respectful maternity care (N=310)
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Method
Advantages
Disadvantages
Facility Exit
• Can obtain a large sample in
a limited amount of time
• Reduces potential for recall
bias
• Cost-effective and logistically
feasible
• Location may lead to courtesy
bias/fear of retribution
• Timing difficult for the woman
(no reflection, distracted by
newborn)
• Home location may reduce
courtesy bias/fear of
retribution
• Allows women more time to
reflect on their experience/
adjust to newborn
• Resource intensive
• Logistically difficult
• Time period too short to
capture changes in care
seeking behavior
self-report
any D&A =
19.5%
Community
follow-up
self-report
any D&A =
28.2%
Maternity
• Captures events and context
observations
surrounding the event
• Not subject to recall bias
observed
• Able to link to other aspects
any D&A =
of quality of care
71.3%
• Does not include the woman’s
perspective
• Resource intensive
(time/skilled observers)
• May measure something
different
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Conclusions and recommendations
• Women’s experiences matter
• Women’s own judgments are shaped by local norms of behavior,
normalization, expectations, and system constraints
• Observations tell us more about the care environment
• The single-item question may be a proxy for
measuring normalization and expectations of the
system
• Used in other settings (Uganda, Tanzania, Zambia) and reveals similar
results
• The question can be further tested
• D&A is one component of women’s delivery experience
• may be more useful to consider D&A as part of a “dignity of care” scale
that also contains RMC items.
20
Thank you
21
Extra slides
22
Types of physical abuse (N=47)
4%
Slapped to push, open
legs (thighs or head)
Slapped to cooperate
26%
47%
Slapped - other
Pushed
23%
Examples:
Slapped to push:
• when pushing the woman tightened her legs, the nurse slapped her on her thigh and told her to
open her legs
• Push you idiot! I am going to slap you. She hit the woman on the head. The woman was not
pushing.
Slapped to cooperate:
• The woman was causing trouble when the nurse was performing the vaginal test, the nurse slapped
her twice on the thigh
• She slapped her when she failed to go up on the delivery bed
Slapped – other: She slapped the patient after refusing to be given anesthesia injection which caused
the nurse to inject herself
Pushed: Move there, why are you so naïve? Is this your first time? Sit properly. The nurse pushed the
woman
23
Types of threatening (N=55)
4%
Scare tactics
7%
Threaten to hurt,
abandon
49%
38%
Traditional herbs
Other
Examples:
Scare tactics:
• If we don’t do that you will get some slight pain, we are stitching you without local anesthesia, if you don’t
do this your partner will run away from you because your sexual parts will be very large
• You will kill your baby if you tighten your legs
Threat to hurt or abandon:
• I will beat you, when the woman refused to open her legs
• I will leave you because of your noises, I will stop helping you and go to sit
Traditional herbs: You are going to die if you don’t want to speak the truth. Did you take traditional herbs?
Other: After you finished here, go to the family planning clinic or I will put a method in you
24
Types of negative comments (N=113)
4%
Patient attribute
9%
Noise
27%
10%
Other - mild
Many pregnancies
Ignorance
12%
Reference to sex
20%
Other - severe
19%
25
Types of negative comments
Patient attribute:
• Where did you find this dirty mackintosh, it looks like a canvas of rain!
• What tribe do you belong to that you cant understand Kiswahili? Are you Mang’ati
or..?
• Look how you are suffering with that abdomen, that is the result of rushing into life.
How are you going to take care of the children?
Noise: The patient was calling for the nurse, the nurse told her, why are you crying
while others have been seen and they are not making noises?
Other – mild: Bring your waist down! It’s as if you are dancing.
Many pregnancies:
• You have delivered several times, this is your eighth pregnancy and you don’t
know how you can get sterilized? Don’t you get this training from your home?
• This is your sixth pregnancy and you come for delivery with only 2 kangas and
your pants so dirty?
Ignorance: You are a teacher and you pretend not knowing where the baby is
passing? It will pass from down there.
Reference to sex: Why are you tightening your legs? My fingers are not big like the
penis that entered here.
Other – severe: The woman had a slight tear, she was afraid that the nurse wanted
to stitch her. The nurse told her, “for your information, your husband is going to leave
you and look for a beautiful woman with a tight vagina”
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Observations: main findings
• More individual episodes of D&A observed than
reported by women:
• 32% of observations recorded 2 or more D&A events on
observation vs. 21% of self-reports on exit
• No correlation between observations and self-
reporting on exit (chi-square, paired t-test)
• No clear pattern of associations between
demographic factors and reports of any D&A on
observation
27
Why is the observed any D&A much
higher than the self-report any D&A?
• Measurement error?
• Measures something different?
28
Measurement error?
Observer Validity
• No association between number of hours observed and
report of “any D&A” by observers
• Removing 3 “outliers” did not change results
Data quality assurance
• Two people coded contextual information provided by the
observers to determine if event was D&A
• Recoded any events that were not D&A or wrongly
categorized
• Recoding did not significantly affect “any D&A” measure
or individual events of D&A
29
Measuring something different?
• Observers were highly sensitized to detect D&A – many
marginal events recorded
• Observers were not asked to rate the severity of the D&A
they observed and women might only recall events they
perceived as severe
• Observers were not asked to rate the quality of care for
labor overall
Observers and women are not reporting the
same events as D&A
30
Women’s reports of satisfaction and quality of
care: comparison across study samples
31
a Versus
somewhat satisfied, somewhat dissatisfied, very dissatisfied
Recent development: Influence of postpartum depression
• In community follow-up survey, women were asked
questions from the Edinburgh Post-partum Depression
Scale (10 questions)
• Of the women who met the criteria for postpartum
depression, more of them reported D&A on follow-up than
they did on exit
• Women were 3 times more likely to be depressed if they
reported D&A on follow-up
Post-partum
depression
D&A on exit
D&A on follow-up
OR: 1.21 (p=0.56)
OR: 3.23 (p<0.001)
32
Proposed next steps
• Develop and test a “dignity of care” index
• Combination of D&A and RMC concepts/events
• Include questions on trust, support, humane care
• Test index in a population-based sample in 1-2
countries
• Explore how this index is linked to longer-term effects
on care-seeking
33
Facility exit interview waterfall analysis
Women discharged from
study facilities (n=2,673)
Women approached for
interviews (n=2,520)
698 did not agree to
participate
1,822 (72.30%) women
agreed to participate
43 had a tablet
malfunction/record lost
1,779 women interviewed
Community Follow-up Waterfall Analysis
Women who consented
to be followed and
completed the facility exit
survey (n=1532)
Randomly selected for
follow-up (n=915)
133 lived outside the
study districts or remote
areas and were deemed
ineligible
Eligible for follow-up
(n=782)
593 (75.83%) interviewed
for community follow-up
190 were not interviewed:
• 149 not found
• 23 missing data
• 7 refused consent
• 6 mother or child dead
• 4 not followed