Barriers to provision of respectful maternity care in Zambia: results from a qualitative study through the lens of behavioral science

Smith, Jana; Banay, Rachel F.; Zimmerman, Emily; Caetano, Vivien; Musheke, Maurice; Kamanga, Ameck

doi:10.1186/s12884-019-2579-x

“…While we were unable to attribute the observed effects to particular components of the solution package, our results suggest that all but one of the ve solutions, the fresh start funds, contributed meaningfully to these positive results. This aligns with the ndings from our formative research phase, and highlights the value of the behavioral design approach which allowed us to identify a range of behavioral drivers impacting provision of RMC and established the need for a multi-faceted solution to address these challenges (5).…”

Section: Discussionsupporting

confidence: 71%

“…One speci c nding from our formative research was that providers had a narrowly de ned mental model of their role which focused on clinical tasks and avoiding client or infant death (5). One objective of the solutions was to expand the providers' mental model of their role to include pain management support as a means for improving client experience.…”

Section: Discussionmentioning

confidence: 99%

“…Formative research conducted through a behavioral science lens in Chipata, Zambia demonstrated that disrespectful care was prevalent and providers experienced several behavioral barriers to provision of respectful maternity care (5). Building on these ndings, we developed and tested evidencebased, low-cost solutions to promote RMC and that have the potential to be scaled.…”

Section: Introductionmentioning

confidence: 99%

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Promoting Respectful Maternity Care using a Behavioral Design Approach in Zambia: Results from a Mixed-Methods Evaluation

Smith

¹

,

Schachter

²

,

Banay

³

et al. 2021

Preprint

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0

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Background: Respectful maternity care (RMC) has been elevated in the global discourse, however, instances of disrespect and abuse remain prevalent. While several studies have highlighted promising approaches to promote RMC, this body of literature is still limited and few approaches have been scaled outside the initial study sites. Building on formative research conducted through a behavioral science lens, we sought to develop and test evidence-based, low-cost solutions to promote RMC which would be well-positioned for scale-up. Our study highlights the effectiveness of the solution package on provider provision of better care and client satisfaction, as well as intermediary outcomes and behavioral mechanisms. Methods: A quasi-experimental evaluation, informed by the behavioral design approach, was completed to test the effectiveness of a 5-component solution package in Chipata, Zambia. Quantitative surveys were collected from health facility providers and postpartum clients at baseline and endline in intervention and comparison facilities. Additional qualitative interviews were conducted with health facility providers and postpartum clients at endline. We also conducted interviews with health facility in-charges and observed labor and delivery practices at intervention facilities over the course of implementation. Results: Evidence suggested that at endline, clients at implementation facilities were less likely to experience disrespect and abuse compared to clients at comparison facilities (ß= -0.15 p=.01). Clients at intervention facilities were more likely to request pain management compared to clients at comparison facilities (ß=.33, p=.003). The solutions were simple for providers to implement and were easily integrated into existing services by providers during labor and delivery. Providers at intervention facilities also described the pain management toolkit as helpful in expanding the types of pain management techniques used during labor.Conclusions: The results of this small-scale study act as a proof of concept, demonstrating that the behavioral design approach can lead to solutions that show potential for impact. In other settings where providers face similar barriers to providing RMC, an adaptation of this solution package might lead to similarly positive results. Given the global scale of disrespectful care, these low-cost solutions hold promise for improving the quality of care women receive during labor and delivery.

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“…After finalizing the process map, we then systematically generated hypotheses about behavioral barriers that facility-based providers may face in attempting to follow best practices for PPH detection and management during childbirth, and the factors in the environment that might contribute to these barriers. Hypotheses arose out of a series of organizationally-developed question prompts, which cover different psychological principles and insights from behavioral sciences, and reviews of other studies on related provider behaviors in resource-limited settings [ 15 , 17 ]. Hypotheses sought to explain why providers who have been trained on best practices for PPH prevention and management might fail to follow them consistently.…”

Section: Methodsmentioning

confidence: 99%

Barriers inhibiting effective detection and management of postpartum hemorrhage during facility-based births in Madagascar: findings from a qualitative study using a behavioral science lens

Flanagan

¹

,

Razafinamanana

²

,

Warren

³

et al. 2021

BMC Pregnancy Childbirth

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Background Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other low-income countries observe low provider adherence to recommended practices for PPH prevention and treatment. Our study addresses gaps in the literature by applying a behavioral science lens to identify barriers inhibiting facility-based providers’ consistent following of PPH best practices in Madagascar. Methods In June 2019, we undertook a cross-sectional qualitative research study in peri-urban and rural areas of the Vatovavy-Fitovinany region of Madagascar. We conducted 47 in-depth interviews in 19 facilities and five communities, with facility-based healthcare providers, postpartum women, medical supervisors, community health volunteers, and traditional birth attendants, and conducted thematic analysis of the transcripts. Results We identified seven key behavioral insights representing a range of factors that may contribute to delays in appropriate PPH management in these settings. Findings suggest providers’ perceived low risk of PPH may influence their compliance with best practices, subconsciously or explicitly, and lead them to undervalue the importance of PPH prevention and monitoring measures. Providers lack clear feedback on specific components of their performance, which ultimately inhibits continuous improvement of compliance with best practices. Providers demonstrate great resourcefulness while operating in a challenging context with limited equipment, supplies, and support; however, overcoming these challenges remains their foremost concern. This response to chronic scarcity is cognitively taxing and may ultimately affect clinical decision-making. Conclusions Our study reveals how perception of low risk of PPH, limited feedback on compliance with best practices and consequences of current practices, and a context of scarcity may negatively affect provider decision-making and clinical practices. Behaviorally informed interventions, designed for specific contexts that care providers operate in, can help improve quality of care and health outcomes for women in labor and childbirth.

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“…First, we de ned the problem and then conducted qualitative, formative research to identify the behavioral barriers inhibiting the provision of RMC. The behavioral barriers and their accompanying contextual features identi ed in this formative research are described in Table 1 and are published elsewhere (5). Pain is seen as a natural birth experience-the provider had a painful delivery, has attended many painful deliveries, and the bible says that labor is painful X X X…”

Section: Intervention and Evaluation Designmentioning

confidence: 99%

Promoting Respectful Maternity Care using a Behavioral Design Approach in Zambia: Results from a Mixed-Methods Evaluation

Smith

¹

,

Schachter

²

,

Banay

³

et al. 2020

Preprint

Self Cite

2

0

View full text Add to dashboard Cite

Background: Respectful maternity care (RMC) has been elevated in the global discourse, however, instances of disrespect and abuse remain prevalent. While several studies have highlighted promising approaches to promote RMC, this body of literature is still limited and few approaches have been scaled outside the initial study sites. Building on formative research conducted through a behavioral science lens, we sought to develop and test evidence-based, low-cost solutions to promote RMC which would be well-positioned for scale-up. Our study highlights the effectiveness of the solution package on provider provision of better care and client satisfaction, as well as intermediary outcomes and behavioral mechanisms. Methods: A quasi-experimental evaluation, informed by the behavioral design approach, was completed to test the effectiveness of a 5-component solution package in Chipata, Zambia. Quantitative surveys were collected from health facility providers and postpartum clients at baseline and endline in intervention and comparison facilities. Additional qualitative interviews were conducted with health facility providers and postpartum clients at endline. We also conducted interviews with health facility in-charges and observed labor and delivery practices at intervention facilities over the course of implementation. Results: Evidence suggested that at endline, clients at implementation facilities were less likely to experience disrespect and abuse compared to clients at comparison facilities (ß= -0.15 p=.01). Clients at intervention facilities were more likely to request pain management compared to clients at comparison facilities (ß=.33, p=.003). The solutions were simple for providers to implement and were easily integrated into existing services by providers during labor and delivery. Providers at intervention facilities also described the pain management toolkit as helpful in expanding the types of pain management techniques used during labor.Conclusions: The results of this small-scale study act as a proof of concept, demonstrating that the behavioral design approach can lead to solutions that show potential for impact. In other settings where providers face similar barriers to providing RMC, an adaptation of this solution package might lead to similarly positive results. Given the global scale of disrespectful care, these low-cost solutions hold promise for improving the quality of care women receive during labor and delivery.

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Barriers to provision of respectful maternity care in Zambia: results from a qualitative study through the lens of behavioral science

Cited by 34 publications

References 26 publications

Promoting Respectful Maternity Care using a Behavioral Design Approach in Zambia: Results from a Mixed-Methods Evaluation

Promoting Respectful Maternity Care using a Behavioral Design Approach in Zambia: Results from a Mixed-Methods Evaluation

Barriers inhibiting effective detection and management of postpartum hemorrhage during facility-based births in Madagascar: findings from a qualitative study using a behavioral science lens

Promoting Respectful Maternity Care using a Behavioral Design Approach in Zambia: Results from a Mixed-Methods Evaluation

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