Measuring prevalence of D&A during childbirth in Tanzania:The Staha ProjectRespectful 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.

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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

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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).

 

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Defining disrespect and abuse in facility-based childbirth

Structural level:What women and providers

consider poor care, but is caused by system deficiencies

Deviations from national standards of good quality care

Deviations from human rights standards (available, accessible,

acceptable, quality)

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

Individual level: actions that all agree are D&A

Initial intervention target

Prevalence Measure

Policy Advocacy

Structural level:System deficiencies that lead to poor care that is accepted and

normalized

Individual level

Structural level

Policy Level

population: 2,010,480*

Tanga region, Tanzania

* 2011 estimate by the National Bureau of Statistics based on the 2002 Population and Housing Census

Study setting – Tanga Region

Study setting: Korogwe and Muheza, Tanga

Korogwe: intervention

Muheza: comparison

population: 324,000*

population: 341,166*

* 2011 estimate by the National Bureau of Statistics based on the 2002 Population and Housing Census

4 Sites:District hospital2 health centers1 dispensary

4 Sites:District hospital3 health centers

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

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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-CONFIDENTIAL

CARE

NON-DIGNIFIED CARE

PHYSICAL ABUSE

•Discuss patient’s private health information in public•Share patient’s health information•Patient’s body seen by others

• Shouting at/scolding patient• Threaten to withhold treatment• Negative comments to patient• Threatening comments to patient

•Hitting/slapping/pushing/pinching, etc.•Rape•Sexual abuse• Stitching of episiotomy without anesthesia

• Ignoring patients requests for assistance• No attendant at delivery

NEGLECT

NON-CONSENTED

CARE•Tubal ligation, caesarean or hysterectomy without consent

INAPPROPRIATE DEMANDS FOR

PAYMENT

•Request bribes/informal payments•Mother or baby held at the facility due to failure to pay

Facility exit vs. community follow-up: prevalence of D&A by experience

C-section w/o consent

Hysterectomy w/o consent

Tubal ligation w/o consent

Sexual harrassment

Detention for failure to pay

Rape

Request for bribe

Physical abuse

Delivery without attendant

Lack of physical privacy

Threat of withholding treatment

Threatening or neg comments

Ignored when needed help

Shouting/scolding

-5% 0% 5% 10% 15%

3.1%

5.1%

5.3%

6.2%

6.0%

11.5%

14.2%

13.2%

1.8%

2.7%

3.9%

4.4%

4.2%

5.3%

7.9%

8.7%

Facility Exit (N=1,761) 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

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Observation vs. facility exit: prevalence of D&A by experience

C-section w/o consent

Hysterectomy w/o consent

Tubal ligation w/o consent

Sexual harrassment

Detention for failure to pay

Rape

Request for bribe

Physical abuse

Delivery without attendant

Lack of physical privacy

Threat of withholding treatment

Threatening or neg comments

Ignored when needed help

Shouting/scolding

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

1.6%

12.9%

3.2%

9.1%

5.5%

45.2%

19.7%

45.5%

0.8%

0.8%

0.8%

1.3%

2.3%

2.9%

3.8%

6.3%

Facility Exit (n=240) Observation (N=310)

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D&A prevalence measures

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• binary measure (yes or no) • based upon single question in

interviews

Self-report single item

D&A

• binary measure (any or none)• based upon women reporting

experience of at least one or more of 14 events

Self-report any D&A

• binary measure (any or none) • based upon observation of at

least one or more of 14 events

Observed any D&A

D&A measures

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Facility

Community

Self-report single item(n=1,779)

Self-report any D&A(n=1,761) Self-report

any D&A(n=240)

Self-report any D&A(n=592)

Self-report single item

(n=593)

Observed any D&A(n=310)

Self-report single item

(n=240)

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D&A measures by source

Facility

Community

Self-report single item(n=1,779)

Self-report any D&A(n=1,761) Self-report

any D&A(n=240)

Self-report any D&A(n=592)

Self-report single item

(n=593)

Observed any D&A(n=310)

Self-report single item

(n=240)

6.3%

12.7%

19.5%

28.2%

71.3%

4.2%

10%

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Complexity of Care Environment

Observations of respectful maternity care (N=310)

Same nurses who observed 70% any D&A

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Method Advantages Disadvantages

Facility Exit

self-report any D&A = 19.5%

• 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)

Community follow-up

self-report any D&A = 28.2%

• 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

Maternity observations

observed any D&A = 71.3%

• Captures events and context surrounding the event

• Not subject to recall bias• Able to link to other aspects

of quality of care

• 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.

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Thank you

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Extra slides

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Types of physical abuse (N=47)

47%

23%

26%

4%

Slapped to push, open legs (thighs or head)

Slapped to cooperate

Slapped - other

Pushed

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 herselfPushed: Move there, why are you so naïve? Is this your first time? Sit properly. The nurse pushed the woman

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Types of threatening (N=55)

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

49%

38%

4%7%

Scare tactics

Threaten to hurt, abandon

Traditional herbs

Other

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Types of negative comments (N=113)

27%

20%

19%

12%

10%

9%

4%

Patient attribute

Noise

Other - mild

Many pregnancies

Ignorance

Reference to sex

Other - severe

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Types of negative commentsPatient 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

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Why is the observed any D&A much higher than the self-report any D&A?

• Measurement error?

• Measures something different?

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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

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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

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Women’s reports of satisfaction and quality of care: comparison across study samples

a Versus somewhat satisfied, somewhat dissatisfied, very dissatisfied

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Recent development: Influence of post-partum 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

D&A on exit D&A on follow-up

Post-partum depression

OR: 1.21 (p=0.56) OR: 3.23 (p<0.001)

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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

Facility exit interview waterfall analysis

Women discharged from study facilities (n=2,673)

Women approached for interviews (n=2,520)

1,822 (72.30%) women agreed to participate

698 did not agree 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)

Eligible for follow-up (n=782)

133 lived outside the study districts or remote areas and were deemed

ineligible

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