Hannah Ratcliffe

Disrespect and Abuse During Childbirth in Tanzania: Are Women Living With HIV More Vulnerable?

Introduction:HIV-related stigma and discrimination and disrespect and abuse during childbirth are barriers to use of essential maternal and HIV health services. Greater understanding of the relationship between HIV status and disrespect and abuse during childbirth is required to design interventions to promote womens rights and to increase uptake of and retention in health services; however, few comparative studies of women living with HIV (WLWH) and HIV-negative women exist. Methods:Mixed methods included interviews with postpartum women (n = 2000), direct observation during childbirth (n = 208), structured questionnaires (n = 50), and in-depth interviews (n = 18) with health care providers. Bivariate and multivariate regressions analyzed associations between HIV status and disrespect and abuse, whereas questionnaires and in-depth interviews provided insight into how provider attitudes and workplace culture influence practice. Results:Of the WLWH and HIV-negative women, 12.2% and 15.0% reported experiencing disrespect and abuse during childbirth (P = 0.37), respectively. In adjusted analyses, no significant differences between WLWH and HIV-negative womens experiences of different types of disrespect and abuse were identified, with the exception of WLWH having greater odds of reporting non-consented care (P = 0.03). None of the WLWH reported violations of HIV confidentiality or attributed disrespect and abuse to their HIV status. Provider interviews indicated that training and supervision focused on prevention of vertical HIV transmission had contributed to changing the institutional culture and reducing HIV-related violations. Conclusions:In general, WLWH were not more likely to report disrespect and abuse during childbirth than HIV-negative women. However, the high overall prevalence of disrespect and abuse measured indicates a serious problem. Similar institutional priority as has been given to training and supervision to reduce HIV-related discrimination during childbirth should be focused on ensuring respectful maternity care for all women.

Mitigating disrespect and abuse during childbirth in Tanzania: an exploratory study of the effects of two facility-based interventions in a large public hospital

BackgroundThere is emerging evidence that disrespect and abuse (D&A) during facility-based childbirth is prevalent in countries throughout the world and a barrier to achieving good maternal health outcomes. However, much work remains in the identification of effective interventions to prevent and eliminate D&A during facility-based childbirth. This paper describes an exploratory study conducted in a large referral hospital in Dar es Salaam, Tanzania that sought to measure D&A, introduce a package of interventions to reduce its incidence, and evaluate their effectiveness.MethodsAfter extensive consultation with critical constituencies, two discrete interventions were implemented: (1) Open Birth Days (OBD), a birth preparedness and antenatal care education program, and (2) a workshop for healthcare providers based on the Health Workers for Change curriculum. Each intervention was designed to increase knowledge of patient rights and birth preparedness; increase and improve patient-provider and provider-administrator communication; and improve women’s experience and provider attitudes. The effects of the interventions were assessed using a pre-post design and a range of tools: pre-post questionnaires for OBD participants and pre-post questionnaires for workshop participants; structured interviews with healthcare providers and administrators; structured interviews with women who gave birth at the study facility; and direct observations of patient-provider interactions during labor and delivery.ResultsComparisons before and after the interventions showed an increase in patient and provider knowledge of user rights across multiple dimensions, as well as women’s knowledge of the labor and delivery process. Women reported feeling better prepared for delivery and provider attitudes towards them improved, with providers reporting higher levels of empathy for the women they serve and better interpersonal relationships. Patients and providers reported improved communication, which direct observations confirmed. Additionally, women reported feeling more empowered and confident during delivery. Provider job satisfaction increased substantially from baseline levels, as did user reports of satisfaction and perceptions of care quality.ConclusionsCollectively, the outcomes of this study indicate that the tested interventions have the potential to be successful in promoting outcomes that are prerequisite to reducing disrespect and abuse. However, a more rigorous evaluation is needed to determine the full impact of these interventions.

Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries

Primary health care (PHC) has been recognized as a core component of effective health systems since the early part of the twentieth century. However, despite notable progress, there remains a large gap between what individuals and communities need, and the quality and effectiveness of care delivered. The Primary Health Care Performance Initiative (PHCPI) was established by an international consortium to catalyze improvements in PHC delivery and outcomes in low- and middle-income countries through better measurement and sharing of effective models and practices. PHCPI has developed a framework to illustrate the relationship between key financing, workforce, and supply inputs, and core primary health care functions of first-contact accessibility, comprehensiveness, coordination, continuity, and person-centeredness. The framework provides guidance for more effective assessment of current strengths and gaps in PHC delivery through a core set of 25 key indicators (“Vital Signs”). Emerging best practices that foster high-performing PHC system development are being codified and shared around low- and high-income countries. These measurement and improvement approaches provide countries and implementers with tools to assess the current state of their PHC delivery system and to identify where cross-country learning can accelerate improvements in PHC quality and effectiveness.

Methods used in prevalence studies of disrespect and abuse during facility based childbirth: lessons learned

BackgroundSeveral recent studies have attempted to measure the prevalence of disrespect and abuse (D&A) of women during childbirth in health facilities. Variations in reported prevalence may be associated with differences in study instruments and data collection methods. This systematic review and comparative analysis of methods aims to aggregate and present lessons learned from published studies that quantified the prevalence of Disrespect and Abuse (D&A) during childbirth.MethodsWe conducted a systematic review of the literature in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Five papers met criteria and were included for analysis. We developed an analytical framework depicting the basic elements of epidemiological methodology in prevalence studies and a table of common types of systematic error associated with each of them. We performed a head-to-head comparison of study methods for all five papers. Using these tools, an independent reviewer provided an analysis of the potential for systematic error in the reported prevalence estimates.ResultsSampling techniques, eligibility criteria, categories of D&A selected for study, operational definitions of D&A, summary measures of D&A, and the mode, timing, and setting of data collection all varied in the five studies included in the review. These variations present opportunities for the introduction of biases – in particular selection, courtesy, and recall bias – and challenge the ability to draw comparisons across the studies’ results.ConclusionOur review underscores the need for caution in interpreting or comparing previously reported prevalence estimates of D&A during facility-based childbirth. The lack of standardized definitions, instruments, and study methods used to date in studies designed to quantify D&A in childbirth facilities introduced the potential for systematic error in reported prevalence estimates, and affected their generalizability and comparability. Chief among the lessons to emerge from comparing methods for measuring the prevalence of D&A is recognition of the tension between seeking prevalence measures that are reliable and generalizable, and attempting to avoid loss of validity in the context where the issue is being studied.

Applying a participatory approach to the promotion of a culture of respect during childbirth.

Disrespect and abuse (D&A) during facility-based childbirth is a topic of growing concern and attention globally. Several recent studies have sought to quantify the prevalence of D&A, however little evidence exists about effective interventions to mitigate disrespect and abuse, and promote respectful maternity care. In an accompanying article, we describe the process of selecting, implementing, and evaluating a package of interventions designed to prevent and reduce disrespect and abuse in a large urban hospital in Tanzania. Though that study was not powered to detect a definitive impact on reducing D&A, the results showed important changes in intermediate outcomes associated with this goal. In this commentary, we describe the factors that enabled this effect, especially the participatory approach we adopted to engage key stakeholders throughout the planning and implementation of the program. Based on our experience and findings, we conclude that a visible, sustained, and participatory intervention process; committed facility leadership; management support; and staff engagement throughout the project contributed to a marked change in the culture of the hospital to one that values and promotes respectful maternity care. For these changes to translate into dignified care during childbirth for all women in a sustainable fashion, institutional commitment to providing the necessary resources and staff will be needed.

Primary Health Care That Works: The Costa Rican Experience

Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Ricas innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Ricas experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.

Better Measurement for Performance Improvement in Low- and Middle-Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection

Policy Points: Strengthening accountability through better measurement and reporting is vital to ensure progress in improving quality primary health care (PHC) systems and achieving universal health coverage (UHC). The Primary Health Care Performance Initiative (PHCPI) provides national decision makers and global stakeholders with opportunities to benchmark and accelerate performance improvement through better performance measurement. Results from the initial PHC performance assessments in low‐ and middle‐income countries (LMICs) are helping guide PHC reforms and investments and improve the PHCPIs instruments and indicators. Findings from future assessment activities will further amplify cross‐country comparisons and peer learning to improve PHC. New indicators and sources of data are needed to better understand PHC system performance in LMICs. Context The Primary Health Care Performance Initiative (PHCPI), a collaboration between the Bill and Melinda Gates Foundation, The World Bank, and the World Health Organization, in partnership with Ariadne Labs and Results for Development, was launched in 2015 with the aim of catalyzing improvements in primary health care (PHC) systems in 135 low‐ and middle‐income countries (LMICs), in order to accelerate progress toward universal health coverage. Through more comprehensive and actionable measurement of quality PHC, the PHCPI stimulates peer learning among LMICs and informs decision makers to guide PHC investments and reforms. Instruments for performance assessment and improvement are in development; to date, a conceptual framework and 2 sets of performance indicators have been released. Methods The PHCPI team developed the conceptual framework through literature reviews and consultations with an advisory committee of international experts. We generated 2 sets of performance indicators selected from a literature review of relevant indicators, cross‐referenced against indicators available from international sources, and evaluated through 2 separate modified Delphi processes, consisting of online surveys and in‐person facilitated discussions with experts. Findings The PHCPI conceptual framework builds on the current understanding of PHC system performance through an expanded emphasis on the role of service delivery. The first set of performance indicators, 36 Vital Signs, facilitates comparisons across countries and over time. The second set, 56 Diagnostic Indicators, elucidates underlying drivers of performance. Key challenges include a lack of available data for several indicators and a lack of validated indicators for important dimensions of quality PHC. Conclusions The availability of data is critical to assessing PHC performance, particularly patient experience and quality of care. The PHCPI will continue to develop and test additional performance assessment instruments, including composite indices and national performance dashboards. Through country engagement, the PHCPI will further refine its instruments and engage with governments to better design and finance primary health care reforms.

Prevalence and factors associated with burnout among frontline primary health care providers in low- and middle-income countries: A systematic review

Background: Primary health care (PHC) systems require motivated and well-trained frontline providers, but are increasingly challenged by the growing global shortage of health care workers. Burnout, defined as emotional exhaustion, depersonalization, and low personal achievement, negatively impacts motivation and may further decrease productivity of already limited workforces. The objective of this review was to analyze the prevalence of and factors associated with provider burnout in low and middle-income countries (LMICs). Methods: We performed a systematic review of articles on outpatient provider burnout in LMICs published up to 2016 in three electronic databases (EMBASE, MEDLINE, and CAB). Articles were reviewed to identify prevalence of factors associated with provider burnout. Results: A total of 6,182 articles were identified, with 20 meeting eligibility criteria. We found heterogeneity in definition and prevalence of burnout. Most studies assessed burnout using the Maslach Burnout Inventory. All three dimensions of burnout were seen across multiple cadres (physicians, nurses, community health workers, midwives, and pharmacists). Frontline nurses in South Africa had the highest prevalence of high emotional exhaustion and depersonalization, while PHC providers in Lebanon had the highest reported prevalence of low personal achievement. Higher provider burnout (for example, among nurses, pharmacists, and rural health workers) was associated with high job stress, high time pressure and workload, and lack of organizational support. Conclusions: Our comprehensive review of published literature showed that provider burnout is prevalent across various health care providers in LMICs. Further studies are required to better measure the causes and consequences of burnout and guide the development of effective interventions to reduce or prevent burnout.Background: Primary health care (PHC) systems require motivated and well-trained frontline providers, but are increasingly challenged by the growing global shortage of health care workers. Burnout, defined as emotional exhaustion, depersonalization, and low personal achievement, negatively impacts motivation and may further decrease productivity of already limited workforces. The objective of this review was to analyze the prevalence of and factors associated with provider burnout in low and middle-income countries (LMICs). Methods: We performed a systematic review of articles on outpatient provider burnout in LMICs published up to 2016 in three electronic databases (EMBASE, MEDLINE, and CAB). Articles were reviewed to identify prevalence of factors associated with provider burnout. Results: A total of 6,182 articles were identified, with 20 meeting eligibility criteria. We found heterogeneity in definition and prevalence of burnout. Most studies assessed burnout using the Maslach Burnout Inventory. All three dimensions of burnout were seen across multiple cadres (physicians, nurses, community health workers, midwives, and pharmacists). Frontline nurses in South Africa had the highest prevalence of high emotional exhaustion and depersonalization, while PHC providers in Lebanon had the highest reported prevalence of low personal achievement. Higher provider burnout (for example, among nurses, pharmacists, and rural health workers) was associated with high job stress, high time pressure and workload, and lack of organizational support. Conclusions: Our comprehensive review of published literature showed that provider burnout is prevalent across various health care providers in LMICs. Further studies are required to better measure the causes and consequences of burnout and guide the development of effective interventions to reduce or prevent burnout.

Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia

Abstract Disrespect and abuse (D&A) experienced by women during facility-based childbirth has gained global recognition as a threat to eliminating preventable maternal mortality and morbidity. This study explored the frequency and associated factors of D&A in four rural health centres in Ethiopia. Experiences of women who delivered in these facilities were captured by direct observation of client-provider interaction (N = 193) and exit interview at time of discharge (N = 204). Incidence of D&A was observed in each facility, with failure to ask woman for preferred birth position most commonly observed [n = 162, 83.9%, 95% confidence interval (95% CI) 78.0–88.5%]. During exit interviews, 21.1% (n = 43, 95% CI 15.4–26.7%) of respondents reported at least one occurrence of D&A. Bivariate models using client characteristics and index birth experience showed that women’s reporting of D&A was significantly associated with childbirth complications [odds ratio (OR) = 7.98, 95% CI 3.70, 17.22], weekend delivery (OR = 0.17, 95% CI 0.05, 0.63) and no previous delivery at the facility (OR = 3.20, 95% CI 1.27, 8.05). Facility-level fixed-effect models found that experience of complications (OR = 15.51, 95% CI 4.38, 54.94) and weekend delivery (OR = 0.05, 95% CI 0.01–0.32) remained significantly and most strongly associated with self-reported D&A. These data suggest that addressing D&A in health centres in Ethiopia will require a sustained effort to improve infrastructure, support the health workforce in rural settings, enforce professional standards and target interventions to improve women’s experiences as part of quality of care initiatives.

The 5S-5M-5C schematic: transforming primary care inputs to outcomes in low-income and middle-income countries

### Summary box High-quality primary healthcare (PHC) is the most effective way to deliver person-centred, promotive, preventive and curative services to meet the majority of a population’s health needs.1 PHC is critical to improving population health, making health systems more equitable and resilient and promoting global health security. Furthermore, PHC is instrumental to achieving quality universal health coverage (UHC) and meeting the Sustainable Development Goals. However, as the global community marks the 40th anniversary of the Alma Ata Declaration in 2018,2 a significant gap remains between the original Declaration’s aspirational vision and the current reality of PHC throughout the world. PHC remains a neglected area of investment in most low-income and middle-income countries (LMICs), with limited prioritisation in public sector spending, poor integration with other sectors and alarming deficiencies in the quality of primary care (PC) clinical services delivered.3 Visits in PC are short, diagnoses frequently incorrect and treatments often unnecessary or harmful.4 Community priorities around healthcare needs are often not elicited within PHC and feedback from patients and communities is rarely sought. To support PHC strengthening and improvement …