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

Abstract

BackgroundDespite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care.MethodsWe used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages.ResultsThe implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima’s successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care.ConclusionWe found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to understanding a range of interventions that can begin to address issues of mistreatment in maternity care; replication of these activities is needed globally to better understand if the Heshima implementation process can be successful in different countries and regions.

A qualitative study on midwives’ identity and perspectives on the occurrence of disrespect and abuse in Maputo city

“…Some promising results have been found from the implementation of a workshop called “Health Workers for Change” in Tanzania covering reflection and discussion about different topics such as own values, women’s status in society and overcoming obstacles at work [ 50 ]. The Population Council’s Heshima Project in Kenya successfully used a similar approach [ 51 ]. While these training sessions have been implemented as in-service interventions for working midwives, it would be interesting to include and evaluate a similar module within the national curriculum for midwifery education.…”

Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: a systematic review

“…The unit of analysis for most of the articles was health providers in facilities or communities involved in implementation (n = 19), followed by organizations (e.g., health facilities, district health offices) involved in implementation (n = 12), patients benefiting from the intervention (n = 7), and policymakers and health system leaders at national or subnational levels (n = 5). Nine of the studies focused upon more than one unit of analysis [10,13,14,16,30,35,39,40,42].…”

Confronting the culture of care: a call to end disrespect, discrimination, and detainment of women and newborns in health facilities everywhere

“…Where fees are still in place, costs must be transparent, waivers must be available, and those unable to pay or bring in-kind goods should never be penalized, scolded, or detained. Although larger system changes are needed to improve the working conditions of facility staff so they can provide better care, some programs that focus on provider reflection and acknowledgement of implicit bias and marginalizing practices, such as values clarification and attitude transformation exercises, have shown impact on improving respectful interactions between those needing and providing care [18,19]. Because poor quality of care prevents care utilization, research has been primarily focused in regions of low facility-based coverage, especially for maternal and neonatal health.…”