Reena Sethi Sr. M&E Advisor Jhpiego Respectful Maternity Care (RMC) in Malawi: Secondary Analysis of Labor and Delivery Observations Reena Sethi Sr. M&E Advisor Jhpiego

Presentation Outline Objectives Setting Other studies on respectful maternity care (RMC) in Malawi Descriptive results from labor and delivery (L&D) observations Summary of findings Strengths and limitations

Objective of the Analysis To present the frequency of observed RMC during labor and delivery among women delivering in 40 high-volume government health facilities in Malawi through secondary data analysis

Setting: Malawi Population 17.4 million (2014)* GDP: $3.68 billion (2013)* Low income Health indicators Maternal mortality ratio 460 deaths per 100,000 live births Neonatal mortality rate 25 deaths per 1,000 live births Total fertility rate 6.0 children born/woman Health worker density 1.39 HWs/1,000 population *Source: CIA World Factbook (est)

Setting: Malawi Institutional delivery rate: 73% 71% of births attended by a skilled birth attendant Source: Malawi DHS 2010 A Malawian mother with her two children in Mzimba District, Malawi.© 2008 Lisa Basalla, Courtesy of Photoshare

Previous Studies of RMC in Malawi Seljeskog et al. 2006: Factors influencing women's choice of place of delivery in rural Malawi: An explorative study Staff in L&D wards did not communicate and kept women waiting Deliveries without provider assistance Privacy was difficult to achieve Changole et al. 2010: Patients’ satisfaction with reproductive health services at Gogo Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi 99.1% of respondents found their interaction with the provider was either good or very good 57.4% knew that it is the right of the patient to have considerate and respectful care

Studies of RMC in Malawi Kumbani et al. 2012: Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi Negative experiences of care included the following: Provider attitudes Delays in care Unavailability of birth attendant Kumbani et al. 2013: Why some women fail to give birth at health facilities: A qualitative study of women’s perceptions of perinatal care from rural Southern Malawi Health workers shouted at them Not always informed of findings

Data Source Labor and delivery observations from Helping Babies Breathe Evaluation in Malawi (secondary data) 27 districts 40 health facilities with 5+ deliveries/day Facility Type Number of facilities Number of L&D observations (all) Number of L&D observations (first stage of labor) Central Hospital 1 114 11 District Hospital 22 1,343 126 Health Center 16 606 67 Rural Hospital 46 4 Total 40 2109 208

Number of observations Frequency of occurrence Non-Dignified Care Number of observations Number of occurrences Frequency of occurrence Provider does not respectfully greet pregnant woman 208 29 13.9% Provider shouts, insults, or threatens the woman during labor or after 2,109 41 1.9%

Number of observations Frequency of occurrence Non-Dignified Care Number of observations Number of occurrences Frequency of occurrence Provider does not encourage the woman to have a support person present during labor and delivery 208 173 83.2% Support person or companion for mother is not present at birth 2,079 1,818 87.4% If support person is not present at birth, support person is restricted from being present 210 11.6%

Number of observations Frequency of occurrence Non-Consented Care Number of observations Number of occurrences Frequency of occurrence Provider does not ask woman (and support person) if she has any questions 208 152 73.1% Provider does not explain procedures to woman (and support person) before proceeding 205 35 17.1%

Number of observations Frequency of occurrence Non-Consented Care Number of observations Number of occurrences Frequency of occurrence Provider does not inform the woman what will happen before conducting the vaginal examination 205 42 20.5% Provider does not inform pregnant woman of findings 200 20 10.0%

Non-Confidential Care Number of observations Number of occurrences Frequency of occurrence Woman does not have audio and visual privacy 208 121 58.2% Provider does not drape woman (one drape under buttocks, one over abdomen)* 152 73.1% *current standard in Malawi is the use of one drape

Non-Confidential Care Number of observations Number of occurrences Frequency of occurrence Woman does not have her own bed (not sharing) 208 5 2.4% Provider does not use curtains or other visual barriers to protect woman during exams, births, procedures 206 54 26.2%

Abandonment or Denial of Care Number of observations Number of occurrences Frequency of occurrence Provider does not encourage woman to consume fluids/food at least once during labor 208 70 33.7% Provider does not encourage or assist woman to ambulate and assume different positions at least once during labor 58 27.9% Provider does not ask woman which position she would like to deliver in 207 194 93.7%

Abandonment or Denial of Care Number of observations Number of occurrences Frequency of occurrence Woman requested some pain relief for her pain but was not given anything 132 66 50.0% Woman was not allowed to deliver in her preferred birthing position (if she had a preferred position) 273 36 13.2% Mother and newborn were not kept in same room after delivery (rooming in) 1,781 249 14.0%

Number of observations Frequency of occurrence Physical Abuse Number of observations Number of occurrences Frequency of occurrence Provider slaps, hits, or pinches the woman during labor or after 2,109 4 0.2%

Summary of Findings Physical abuse was rare Provider-client communication occurred more frequently in the direction of the provider to the client and less frequently from the client to the provider A small proportion of women had a support person present Privacy was an issue in a majority of cases—both audio/visual privacy and personal privacy Most women were not asked about their preferred birthing position

Recommendations Reinforce RMC during BEmONC trainings and as part of quality improvement standards for labor and delivery Include RMC in coaching and mentoring Maternity in-charges to facilitate RMC through supervision

Strengths & Limitations Direct observations may be an objective measurement method Possible Hawthorne effect Unable to observe all components of Rights of Childbearing Women framework Relatively small sample size for RMC items in the first stage of labor

Thank you! Malawi HBB Evaluation Team: Shivam Gupta, Abigail Kazembe, Angella Mtimuni, Reena Sethi, Lolade Oseni, Tambudzai Rashidi, Evelyn Zimba, Stella Abwao, Barbara Rawlins, Fannie Kachale