Quality of Care: Importance of person-centered care in the era of Universal Health Coverage

Critical time for quality of care Better health outcomes through improvement in quality Building quality mechanisms into the foundations of health systems All governments should have a national quality policy and strategy 3 reports on quality of care emerged in 2018 Importance of redefining health system quality beyond the Donabeidan model The way we typically measure progress in UHC is through effective coverage of essential health services and financial protection (ensuring that no one becomes impoverished because of ill-health). But even if the world achieved essential health coverage and financial protection, health outcomes would still be poor if services were low-quality and unsafe. Delivering quality health services is essential to UHC. Measuring user’s experience; June 2018 August 2018 September 2018

WHO Vision - Quality of Care Framework WHO Vision of Qoc Research shows that it is necessary to go beyond maximizing coverage of essential interventions to accelerate reductions in maternal and perinatal mortality and severe morbidity. Moreover, there is a complex interplay of experiences of mistreatment and lack of support that impact women’s childbirth experiences and outcomes. Quality of care is considered a key component of the right to health Coverage of essential interventions is not enough - Every mother and newborn should receive quality care throughout the pregnancy, childbirth and postnatal periods Efforts to achieve Universal Health Coverage are aimed to provide all women, children and adolescents access to the health care system WHO standards for improving quality of maternal and newborn care in health facilities Eight domains of quality of care that should be assessed, improved and monitored within the health system Standards of care and measures of quality define what is required in order to achieve quality care: Quality statements Quality measures: input, process and outcome measures Standard 4: Communication with women and their families is effective and in response to their needs and preferences. Standard 5: Women and newborns receive care with respect and dignity. Standard 6: Every woman and her family are provided with emotional support that is sensitive to their needs and strengthens her own capabilities. http://apps.who.int/iris/bitstream/10665/249

Highlights from WHO’s research and normative work

WHO technical consultation (2013) Background Bowser and Hill (2010) Landscape analysis outlining the issue of disrespect and abuse during childbirth WHO technical consultation (2013) Develop a universal typology of the mistreatment of women during childbirth; and Initiate research activities to develop, validate and apply measurement tools to measure the prevalence of this mistreatment. WHO statement (2014) “Prevention and elimination of disrespect and abuse during childbirth”

Framing and terminology Obstetric violence Disrespect and abuse Mistreatment Respectful care Different terminology used to describe this phenomenon: Obstetric violence (mainly used in Latin America) Disrespect and abuse Respectful maternity care Mistreatment of women during childbirth Places women at the center  woman-centered measurement approaches Non-judgmental language, does not assign blame Intentional and non-intentional behaviours May result from health systems constraints rather than malicious intent May be experienced at an interpersonal level (woman & provider) or more nuanced during women’s interactions with health system Helps to form multi-disciplinary groups of women, communities, midwives, doctors, researchers, policy-makers… Importance of RMC Provision of respectful maternity care is in accordance with a human rights-based approach to reducing maternal morbidity and mortality could improve women’s experience of labour and childbirth and address health inequalities. RMC is a broader concept than merely preventing the mistreatment of women at birth. RMC can be supported and promoted at all three levels of health care (individual, health facility, and health system).

Background WHO Multi-country Study: How women are treated during facility-based childbirth (2015-2018) WHO conducted a mixed-methods systematic review to develop a typology of what constitutes mistreatment of women during childbirth: Typology: physical abuse sexual abuse verbal abuse stigma and discrimination, failure to meet professional standards of care poor rapport between women and providers health system conditions and constraints 65 studies conducted across 34 countries Developed a typology of what constitutes mistreatment during childbirth, from the perspectives of women, community members, health workers, and administrators Building block for our work in this area

How women are treated during facility-based childbirth (2015-2018) Two phased multi-country study: Phase 1: Qualitative formative research to explore what constitutes mistreatment during childbirth Phase 2: Develop and validate two tools to measure mistreatment during childbirth (prevalence results in press in the Lancet): Labour observation tool Community survey tool Four countries: Nigeria Ghana Guinea Myanmar Bohren et al systematic review: 65 studies conducted across 34 countries Typology of what constitutes mistreatment during childbirth, from the perspectives of women, community members, health workers, and administrators Building block for our work in this area Publication of Phase I findings have been completed including most recent from Ghana in RHM special issue – August 2018 Domains of interest were: Decision-making processes to give birth at a facility Expectations of care Expectations and experiences of mistreatment during childbirth Perceived factors influencing mistreatment of women during childbirth Acceptability of scenarios of mistreatment during childbirth Treatment of staff by colleagues and supervisors Phase II Phase II data collection completed – March 2018 ; Phase II principal investigator’s meeting – July 2018 Phase II tool development methodology paper was published – November 2018 Tools publicly available via publication Preliminary findings from Phase II presented at FIGO, publications on Phase II under review and forthcoming

WHO’s recommendations on intrapartum care Labour and childbirth should be individualised and woman‐centred No intervention should be implemented without a clear medical indication Only interventions that serve an immediate purpose and have been proven to be beneficial should be promoted. A clear objective that a positive childbirth experience for the woman, the newborn, and her family should be at the forefront of labour and childbirth care at all times 56 recommendations; however 3 focus on person-centered care where our research fits into the normative work: Respectful labor and childbirth care Effective communication by staff Emotional support from a companion of choice

Human rights and mistreatment of women Engaging women and accounting for their experiences in health systems is the first order of respect in a human rights approach to maternal care. Enabling environment for women to speak up about their experiences as service users, and listening when they do speak up Women are NOT passive recipients of healthcare services, but active and informed individuals with unique expectations and needs Furthermore, working with other UN agencies to incorporate in the global policy agenda as human rights are important : Enabling environment for women to speak up about their experiences as service users, and listening when they do speak up Women are NOT passive recipients of healthcare services, but active and informed individuals with unique expectations and needs High priority in the global agenda The Special Rapporteur on Violence Against Women (VAW) will be presenting her report at UN General Assembly (October 2019)

Additional slides

How women are treated during facility-based childbirth (2015-2018) -1 Two phased multi-country study: Phase 1: Qualitative formative research to explore what constitutes mistreatment during childbirth Four countries: Nigeria Ghana Guinea Myanmar Bohren et al systematic review: 65 studies conducted across 34 countries Typology of what constitutes mistreatment during childbirth, from the perspectives of women, community members, health workers, and administrators Building block for our work in this area Publication of Phase I findings have been completed including most recent from Ghana in RHM special issue – August 2018 Domains of interest were: Decision-making processes to give birth at a facility Expectations of care Expectations and experiences of mistreatment during childbirth Perceived factors influencing mistreatment of women during childbirth Acceptability of scenarios of mistreatment during childbirth Treatment of staff by colleagues and supervisors

How women are treated during facility-based childbirth (2015-2018) -2 Two phased multi-country study: Phase 2: Develop and validate two tools to measure mistreatment during childbirth: Labour observation tool Community survey tool Results forthcoming in the Lancet (in press) Four countries: Nigeria Ghana Guinea Myanmar Phase II data collection completed – March 2018 ; Phase II principal investigator’s meeting – July 2018 Phase II tool development methodology paper was published – November 2018 Preliminary findings from Phase II presented at FIGO, publications on Phase II under review and forthcoming

Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis (2017) Aim: to develop a conceptualization of RMC from the perspectives of key stakeholders 67 studies included from 32 countries 12 domains of RMC synthesized: Being free from harm and mistreatment Maintaining privacy and confidentiality Preserving women’s dignity Prospective provision of information and seeking of informed consent Ensuring continuous access to family and community support Enhancing quality of physical environment and resources Providing equitable maternity care Engaging with effective communication Respecting women’s choices that strengthen their capabilities to give birth Availability of competent and motivated human resources Provision of efficient and effective care Continuity of care Importance of RMC Provision of respectful maternity care is in accordance with a human rights-based approach to reducing maternal morbidity and mortality could improve women’s experience of labour and childbirth and address health inequalities. RMC is a broader concept than merely preventing the mistreatment of women at birth. RMC can be supported and promoted at all three levels of health care (individual, health facility, and health system).