Providing respectful, high-quality care in Tshwane District Midwife Obstetric units: Implementation of a context-adaptable intervention package Sarie Oosthuizen1, Anne-Marie Bergh2, Robert Pattinson2 1 Tshwane District Health Services and Department of Family Medicine, University of Pretoria 2 SAMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria 14th Annual Conference, Society of Midwives of South Africa Klerksdorp, 22-25 August 2017

Tshwane District Population: 3.7 million Socio-economic quintile 5 50 000 deliveries per annum (2015-6) 8500 (18%) of deliveries in 10 midwife obstetric units (MOUs) 7360 (13%) transferred from MOU to hospital for delivery Population of 3.7 million, with most of the population concentrated in sub districts 1, 3 and 4, while sub districts 2, 5,6 ,7 are peri-urban to rural areas. Question: Do MOUs meet the needs and expectations related to providing quality care?

Study objectives Determine status of respectful birthing care in midwife obstetric units in Tshwane District Design and implement a participatory research intervention in a selected group of MOUs  Monitor: process and progress of implementation Evaluate: Outcomes of intervention Impact of intervention

Mixed-methods study design Sequential phases of research INTERVENTION QUAN QUAL QUAL QUAN Concurrent Ethics approval UP 541/2015 Phase 1 Phase 2 Phase 3 Baseline End line 5 MOUs Control: 5 MOUs

Phase 1: Baseline assessment

Survey of Tshwane mothers’ experiences with childbirth Baseline questionnaire administered simultaneously in all 10 MOUs (n=653) Socio-demographics: age, language, place of residence and years of schooling Areas of mothers’ experiences: communication with mothers, labour experience, clinical care, satisfaction with treatment and perceptions of experience Mother’s experiences, perceptions to barriers of care, expectations and matched then with the labour outcome, communication practices and the sharing of the decisions made during the process of labour = patient satisfaction Study was conducted during February to first week in April. All Facility managers signed consent. Research assistants signed confidentiality clause and were trained on administration of the questionnaire

Satisfaction with treatment and experience n % Treated with respect 307 47.4% Midwives were nice during delivery 364 55.9% Satisfaction with treatment received in labour ward 361 55.2% 287 43.9% 14 2.1%

Mothers’ experiences: what needs to improve? Verbal abuse: shouted at; degrading language; ‘Stop swearing at us’ Physical abuse: harshness and violence during delivery; slapped; ’PV done to hurt me’ Withholding of care: no attention given when shouted repeatedly for help; delivered on the floor or alone (not documented in files) Non-consented care: ’I found the midwife’s fingers inside me’ Discrimination: ’We want equal treatment: we are also human’ Humane treatment: ‘Give us something for pain’ Health system’s impact: ‘Get enough staff’; ’Cleaners were rude’

Conclusion Midwife obstetric units did not meet the needs and expectations of birthing women Interventions should address changes in the context of respectful relationships, cognitive care and attention to maternal needs Respectful care and communication should be linked with midwife competence and quality clinical care

The CLEVER intervention package Phase 2: The CLEVER intervention package The purpose of the study during the second phase was to develop a context-specific intervention package for improving the quality of clinical care and the level of respectful behaviour in MOUs Implementation in 5 intervention facilities, with control group of 5 MOUs

Foundation based on combination of cognitive and behavioural theories Respectful and safe clinical care practices in MOUs improved by working CLEVER: C linical care L abour ward management E liminate barriers V erify care E OST running on autopilot R espectful care Foundation based on combination of cognitive and behavioural theories But the different aspects of the package are imbedded in the micro- meso and macro – levels of the Health system. The

C L E R V Measure Health systems ⇢Managers ⇢Supervision ⇢Environment ⇢Structures ⇢Supplies/drugs ⇢ Steps in implementation Identify the problem Commit to quality improvement cycle Prepare and address the health system Implementation of 12 weekly sessions Support for routine practice Conditions for sustainability: facility managers involved and nominated advanced midwife leaders

Clinical care: obstetric admission and triage with urgency Handover rounds at change of each shift at the mother’s bed to eliminate care delays and blind spots, midwives sign notes Risk evaluation with management plan, next observation time visibly documented in maternity file (reduce litigation) Intrapartum monitoring on partogram and continuation of care Guidelines and flow charts available at triage/admission bed Discussions with night staff, reviewing cases and debriefing Team work; support to take over from each other and mandatory support during emergencies Greeting of mother, communication addressed and naming of relevant midwife to look after each mother

Labour ward management: Resolve withholding of care Within 5-10 min of arrival, mother welcomed by name by a midwife stating her own name Admission/triage bed with equipment and supplies, flow charts Allocation of cases: advanced midwife according to experience/skill Working in teams, taking over when needed Timeous referral of high risk patients to correct level of care After initial assessment, document time of next observation Facility manager with team leader doing weekly rounds in unit to support midwife teams, reaching all midwives during handover of shift

Eliminate barriers: meeting basic human needs Pain management during labour: pethidine and promethazine with signed protocol Cultural birthing practices allowed – squatting Birth partners allowed during labour Food and drinks offered Comfortable clean environment – linen and savers, maternity pads

Verify care: monitoring, evaluation and feedback Team leader reviews care and documentation on partograms Team leaders visible as role models with emphatic care (don’t allow poor care practices and rude communication) Measure care by key indicators and tools Follow mothers’ complaints and experiences during birth Constant feedback to teams and facility manager on birthing mothers’ needs and expectations Balance actions with “what would the professional midwife do?”

Emergency obstetric simulation training (EOST): creating autopilot care in units Reaching all shifts in delivery units Eliminate thinking during emergencies: ensure that skill is so well ingrained that midwives can deliver breech, shoulder dystocia and handle PPH, eclampsia, sepsis and cord prolapse without stress Use different teaching methods: simulated training, videos and discussions with flow charts EOST needs to reach all the teams of midwives in the unit (night and the rotational weekend shifts)

Respectful care: Kind and attentive care reduces complaints and litigation Boundary golden rule of NO SHOUTING AT any mother – may shout WITH mother to encourage her during second stage Eye contact and proper communication with each mother to share information and build trust Dignified, confidential and prompt care when called Named professional midwives Teamwork, taking over from a frustrated midwife, rendering calm professional support, civil to each other Taught how to think before reacting to a difficult situation

End line assessment of working CLEVER Phase 3: End line assessment of working CLEVER

Satisfaction with treatment and experience Baseline End line (Preliminary) % Treated with respect 47.4% 75.6% Midwives were nice during delivery 55.9% 92.0% Satisfaction with treatment received in labour ward 55.2% 73.7% 43.9% 20.8% 2.1%

Impact of working CLEVER Rate per 1000 births* Year Intervention MOUs Control MOUs p value In-facility fresh stillbirths 2015 8.50 8.38 0.005 2016 1.42 5.67 Meconium aspiration 12.24 3.77 0.023 4.52 3.91 Birth asphyxia 15.64 7.53 0.525 5.95 3.56 Mortality rates in 2015 vs 16: marked improvement with p value of 0.005 in fresh stillbirths, while meconium aspiration also improved * For meconium aspiration and birth asphyxia, rate is per 1000 live births Midwives also expressed their satisfaction with the new risk-management routines in labour wards

Conclusion: working CLEVER A context-specific intervention package addressing respectful relationships, cognitive care and attending to maternal needs, linked with midwife competence and quality clinical care routines, improved morbidity and mortality rates in MOUs with improved patient satisfaction outcomes