1. 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, August 2017

2. Tshwane District Population: 3.7 million Socio-economic quintile 5
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?

3. 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

4. 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

5. Phase 1:
Baseline assessment

6. 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

7. 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%

8. 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’

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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?”

17. 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)

18. 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

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

20. 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%

21. 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 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

22. 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