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

2. 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

3. 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.

4. Highlights from WHO’s research and normative work

5. 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”

6. 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).

7. Background WHO Multi-country Study: How women are treated during facility-based childbirth ( )
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

8. 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

9. 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

10. 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)

12. Additional slides

13. 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

14. 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

15. 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).