Pooja Sripad

There's no kind of respect here A qualitative study of racism and access to maternal health care among Romani women in the Balkans

IntroductionRoma, the largest minority group in Europe, face widespread racism and health disadvantage. Using qualitative data from Serbia and Macedonia, our objective was to develop a conceptual framework showing how three levels of racism--personal, internalized, and institutional--affect access to maternal health care among Romani women.MethodsEight focus groups of Romani women aged 14-44 (n = 71), as well as in-depth semi-structured interviews with gynecologists (n = 8) and key informants from NGOs and state institutions (n = 11) were conducted on maternal health care seeking, experiences during care, and perceived health care discrimination. Transcripts were coded, and analyzed using a grounded theory approach. Themes were categorized into domains.ResultsTwenty-two emergent themes identified barriers that reflected how racism affects access to maternal health care. The domains into which the themes were classified were perceptions and interactions with health system, psychological factors, social environment and resources, lack of health system accountability, financial needs, and exclusion from education.ConclusionsThe experiences of Romani women demonstrate psychosocial and structural pathways by which racism and discrimination affect access to prenatal and maternity care. Interventions to address maternal health inequalities should target barriers within all three levels of racism.

Exploring provider perspectives on respectful maternity care in Kenya: “Work with what you have”

BackgroundPromoting respect and dignity is a key component of providing quality care during facility-based childbirth and is becoming a critical indicator of maternal health care. Providing quality care requires essential skills and attitudes from healthcare providers, as their role is central to optimizing interventions in maternity settings.MethodsIn 13 facilities in Kenya we conducted a mixed methods, pre-post study design to assess health providers’ perspectives of a multi-component intervention (the Heshima project), which aimed to mitigate aspects of disrespect and abuse during facility-based childbirth. Providers working in maternity units at study facilities were interviewed using a two-part quantitative questionnaire: an interviewer-guided section on knowledge and practice, and a self-administered section focusing on intrinsic value systems and perceptions. Eleven distinct composite scores were created on client rights and care, provider emotional wellbeing, and work environments. Bivariate analyses compared pre- and post-scores. Qualitative in-depth interviews focused on underlying factors that affected provider attitudes and behaviors including the complexities of service delivery, and perceptions of the Heshima interventions.ResultsComposite scales were developed on provider knowledge of client rights (Chronbach αxa0=xa00.70), client-centered care (αxa0=xa00.80), and HIV care (αxa0=xa00.81); providers’ emotional health (αxa0=xa00.76) and working relationships (αxa0=xa00.88); and provider perceptions of management (αxa0=xa00.93), job fairness (αxa0=xa00.68), supervision (αxa0=xa00.84), promotion (αxa0=xa00.83), health systems (αxa0=xa00.85), and work environment (αxa0=xa00.85). Comparison of baseline and endline individual item scores and composite scores showed that provider knowledge of client rights and practice of a rights-based approach, treatment of clients living with HIV, and client-centered care during labor, delivery, and postnatal periods improved (pxa0<xa00.001). Changes in emotional health, perceptions of management, job fairness, supervision, and promotion seen in composite scores did not directly align with changes in item-specific responses. Qualitative data reveal health system challenges limit the translation of providers’ positive attitudes and behaviors into implementation of a rights-based approach to maternity care.ConclusionBehavior change interventions, central to promoting respectful care, are feasible to implement, as seen in the Heshima experience, but require sustained interaction with health systems where providers practice. Provider emotional health has the potential to drive (mis)treatment and affect women’s care.

Exploring Meaning and Types of Trust in Maternity Care in Peri-Urban Kenya: A Qualitative Cross-Perspective Analysis

Trust offers a distinctive lens on facility responsiveness during labor and birth. Though acknowledged in prior literature, limited work exists linking conceptual and empirical spheres. This study explores trust in the maternity setting in Kenya through a theoretically driven qualitative approach. Focus groups (n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews (n = 33) with WRB, frontline providers, and management, were conducted in and around a peri-urban public hospital. Combined coding and memo-writing showed that trust in maternity care is nested within understandings of institutional and societal trust. Content areas of trust include confidence, communication, integrity, mutual respect, competence, fairness, confidentiality, and systems trust. Trust is relevant, multidimensional, and dynamic. Examining trust provides a basis for developing quantitative measures and reveals structural underpinnings, repercussions for trust in other health areas, and health systems inequities, which have implications for maternal health policy, programming, and service utilization.

Measuring mistreatment of women throughout the birthing process: implications for quality of care assessments

Abstract Measuring mistreatment and quality of care during childbirth is important in promoting respectful maternity care. We describe these dimensions throughout the birthing process from admission, delivery and immediate postpartum care. We observed 677 client–provider interactions and conducted 13 facility assessments in Kenya. We used descriptive statistics and logistic regression model to illustrate how mistreatment and clinical process of care vary through the birthing process. During admission, the prevalence of verbal abuse was 18%, lack of informed consent 59%, and lack of privacy 67%. Women with higher parity were more likely to be verbally abused [AOR: 1.69; (95% CI 1.03,2.77)]. During delivery, low levels of verbal and physical abuse were observed, but lack of privacy and unhygienic practices were prevalent during delivery and postpartum (>65%). Women were less likely to be verbally abused [AOR: 0.88 (95% CI 0.78, 0.99)] or experience unhygienic practices, [AOR: 0.87 (95% CI 0.78, 0.97)] in better-equipped facilities. During admission, providers were observed creating rapport (52%), taking medical history (82%), conducting physical assessments (5%). Women’s likelihood to receive a physical assessment increased with higher infrastructural scores during admission [AOR: 2.52; (95% CI 2.03, 3.21)] and immediately postpartum [AOR 2.18; (95% CI 1.24, 3.82)]. Night-time deliveries were associated with lower likelihood of physical assessment and rapport creation [AOR; 0.58; (95% CI 0.41,0.86)]. The variability of mistreatment and clinical quality of maternity along the birthing process suggests health system drivers that influence provider behaviour and health facility environment should be considered for quality improvement and reduction of mistreatment.

“Sickness of Shame”: Investigating Challenges and Resilience Among Women Living with Obstetric Fistula in Kenya

Silent suffering from unrepaired fistula—a condition that causes women to leak urine or feces—burdens women living in low- and middle-income countries. In Kenya, while many women experience delays in seeking repair due to a number of factors, others demonstrate resilience in accessing care. This mixed methods concurrent design draws on structured questionnaires and case studies with women affected by fistula (n=82) and 16 focus group discussions (FGDs) with men and women in Central, Eastern, and Coastal Kenya. Factors associated with repair care-seeking include telling a spouse, positive spousal reaction, and financial and psychosocial assistance of spouse or siblings (p < 0.05). Loss of dignity and self-worth, feeling rejected, household gender imbalance, beliefs about witchcraft, spousal or familial abandonment, silence around condition, embarrassment to seek care, poverty, cost of transport, husband accompaniment policies, and past unsuccessful repairs represent barriers to care-seeking. In contrast, women who were knowledgeable about treatment, had financial and psychosocial support from spouses and family members, and felt sympathetic altruism of their community were better able to access repair care, adequate follow-up, and reintegrate into social life. In summary, findings show that multiple factors in women’s lives—including their awareness, resolve, and contextually derived support—simultaneously affect their resilience to access free care opportunities. These opportunities may be further modified by health facility and health system factors, and political leadership that shapes the provision and organization of repair services. This implies a need to focus interventions on educating and awareness-raising to destigmatize the condition, empower women, and enhance collective agency.

“Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda

BackgroundWomen living with obstetric fistula often live in poverty and in remote areas far from hospitals offering surgical repair. These women and their families face a range of costs while accessing fistula repair, some of which include: management of their condition, lost productivity and time, and transport to facilities. This study explores, through women’s, communities’, and providers’ perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking repair services.MethodsA qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews (IDIs) with women affected by fistula (nu2009=u200952) – including those awaiting repair, living with fistula, and after repair, and their spouses and other family members (nu2009=u200917), along with health service providers involved in fistula repair and counseling (nu2009=u200938). Focus group discussions (FGDs) with male and female community stakeholders (nu2009=u20098) and post-repair clients (nu2009=u20096) were also conducted.ResultsWomen’s experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. In Uganda, experienced transport costs indicate that women spend Ugandan Shilling (UGX) 10,000 to 90,000 (US

Sowing the seeds of transformative practice to actualize women’s rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research

3.00-US

261. Strengthening Antenatal Care Services for early detection of Pre-Eclampsia and timely delivery: A Case of Three States in Nigeria

25.00) for two people for a single trip to a camp (client and her caregiver), while Nigerian women (Kano) spent Naira 250 to 2000 (US

305. Birth outcomes with early-and late-onset sign/symptoms of preeclampsia/eclampsia: A cross-sectional postpartum study in Bangladesh

0.80-US

287. Contextualizing care for women with pre-eclampsia and eclampsia in Ethiopia: Exploring policy and implementation environments

6.41) for transportation. Factors that influence women’s and families’ ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation.ConclusionsThe concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers.