Promoting respectful maternity care using a behavioral design approach in Zambia: results from a mixed-methods evaluation

Abstract

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 respectful 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 = 0.01). Clients at intervention facilities were more likely to request pain management compared to clients at comparison facilities (ß = 0.33, p = 0.003). 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.

Factors associated with respectful maternity care and influence of HIV status among women giving birth in Kilimanjaro, Tanzania

“…We also understand that the level of education and cadre of the birth attendants can affect the practices of RMC, but it was not possible to obtain this information from the participants or medical record forms. Finally, high self‐reported RMC may sometimes reflect low expectations for care as has been indicated in the literature 46 . This may be the case particularly for WLHIV, who may have even lower expectations of care given their anticipated stigma.…”

“…Finally, high self-reported RMC may sometimes reflect low expectations for care as has been indicated in the literature. 46 This may be the case particularly for WLHIV, who may have even lower expectations of care given their anticipated stigma. A study by Smith and colleagues in Zambia reported that women's primary concern during labor and delivery was to have a healthy baby, which may lead them to minimize abusive behaviors.…”

“…This may be the case particularly for WLHIV, who may have even lower expectations of care given their anticipated stigma. A study by Smith and colleagues in Zambia reported that women's primary concern during labor and delivery was to have a healthy baby, which may lead them to minimize abusive behaviors 46 . As patients become more aware of their rights and develop higher expectations for the care received during birth, it is possible that self‐reported RMC may decrease, even as the quality of care improves.…”

Developing the Promotion of Respectful Maternity Care Strategies for Midwives in Jos, an Intervention Mapping Approach

“…Theoretical techniques of verbal persuasion and modeling, drawn from the Social Cognitive Theory, were used to alter the determinants of attitude, social influence, self-efficacy, and expected outcomes (Smith et al, 2022). Similar to this, the Social Cognitive Theory's active learning and direction were used to influence the determinants' abilities and self-efficacy.…”

Caring for providers to improve patient experience (CPIPE): intervention development process

“…Most interventions in Africa focus on training providers on respectful maternity care [ 59–63 ]. Other interventions include improving the health facility environment, working with policymakers to encourage greater focus on disrespect and abuse of women, and strengthening linkages between the facility and community for accountability and governance [ 28 , 29 , 64 ]. Evidence on the effectiveness of these interventions is however limited, and there remains a dearth of interventions to improve PCMC that are grounded in theory [ 27 , 58 , 59 ].…”