1. Measuring Disrespect and Abuse during Childbirth in the Western Highlands of Guatemala Emily Peca, MA, MPH GWU/USAID|TRAction Project Respectful Maternity Care Seminar June 24, 2014

2. Overview of Presentation Context of Guatemala Opportunity to explore D&A within an existing effort Data source Data collection Preliminary results Contribution

3. Guatemala: Country of Contrasts Disparities in outcomes: by ethnicity, geography, income Key Health Indicators for Guatemala ENSMI 2008-2009 IndicatorNational Non - indigenous Indigenous Dept. of Quiche Maternal Mortality Ratio (UN 2013) 140 per 100,000 -- Infant mortality343040 Fertility3.63.14.55.2 Facility Delivery51%70%29%20% Women < 145 cm tall 31.2%19%48.3%53.9% Chronic malnutrition (under 5) 49.8%36.2%65.9%72.2%

4. The Opportunity TRAction Guatemala’s technical cooperation approach focused on strengthening the network of MNCH & nutrition service delivery in Ixil Health Area Data was collected on health seeking behavior and perceptions related to maternal child health and nutrition services Opportunity: to describe and quantify women’s experiences and perceptions of disrespect and abuse related to facility deliveries

6. Study Site Ixil is comprised of 3 municipalities in the Department of El Quiche Total Pop. Ixil ~160,000 Majority of the population lives in communities of 500 people or less

7. Data Source Qualitative & quantitative data is from 15 rural to remote communities from all three municipalities of Ixil (total pop 7,757) Communities are categorized as close, intermediate or far to nearest delivery facility. (1 public facility in each municipality) Partners COTONEB; University of San Carlos

8. Focus Group Discussions Comadronas- traditional birth attendants Women (home birth)- within last five years Women (facility-birth)- within the last five year s MunicipalityWomen facility birth Women home birth ComadronasTotal Nebaj2125 Cotzal2125 Chajul2215 Total64515

9. In-depth Interviews MunicipalityComm. Leaders Comm. Health Workers Women Facility Birth Total Nebaj34310 Cotzal33410 Chajul4329 Total10 929 Community leaders: religious leaders, leaders of dev’t committees Community health workers: head mini-health posts in each of the 15 communities Women (facility-birth)- within the last five years

10. Domains Domains Consistent across all FGDs & IDIs Reasons for delivering in a facility/home Disrespect and abuse in facilities (experiences/perceptions) Recommendations for improving facility-based services All data was collected by bilingual (Spanish & Ixil) women from the three municipalities of Ixil

11. Preliminary Results: Qualitative Data Contributors to D&A (Adapted) Construct of D&A Consequences of D&A Quotes from women who gave birth in a facility: “I was not attended quickly and when my baby was about to come out they pushed me without saying why, this made me feel bad.” “They gave me cold food and when they drew my blood they never told me why.” “The providers were not at my side when my baby was born …” I needed help and the nurse didn’t want to help me. When I asked her help she just said levantate! (get up!), but I couldn’t.” “They are from the same group as us (Ixil) but they do not speak to us in Ixil and they scold us…” Comadrona (TBA)

12. Preliminary Results: Survey Data NumberPercent Houses visited as part of the census 1590100% Eligible households for survey (child <5) 75447.4% Ineligible households58837% Vacant: 148; absent: 87; refused : 11 94% self-identified as indigenous; 6% non-indigenous 19% gave birth to their last child in a facility; majority give birth with comadronas (TBAs)

13. Survey Data Questions for measuring disrespect & abuse and respect promoting practices were based on: – Disrespectful & Abusive Maternity Care Framework – Disrespect and abuse studies in East Africa – Formative research in Ixil – Guatemala’s guidelines/norms for culturally appropriate care (Disrespect/Abuse) Bribe Neglect Non-consent Neg. gestures/comment (Respect Promoting) Language Birth Companion Chose Position Preferred clothing (Disrespect/Abuse) Bribe Neglect Non-consent Neg. gestures/comment (Respect Promoting) Language Birth Companion Chose Position Preferred clothing

14. D&A/RMC Questions Survey included two sets of similar disrespect and abuse questions for women who had a home birth & women who had a facility birth – Facility birth cohort: asked about their own experiences – Home birth cohort: asked about perceptions/beliefs about facility births This allows for comparison between self-reported experiences and beliefs/perceptions

15. D&A: Facility Cohort At any time during your stay at facility “X” did they do something to you that made you feel bad? AnswernfrequencyCI Yes, they did something to me 106.92.711.1 No, they did not do something to me 13493.188.997.3 Total144100 “Global” disrespect and abuse question (facility cohort) indicates 7% prevalence

16. Results: comparison of experiences vs. perceptions D&A Item (% reported "yes") facility cohort (n=144) home cohort (n=598) Neglect12% (17)9% (51) Pay/give something for better care6% (9)9% (51) Negative body language/comments4% (6)n/a Non-consent9% (13)n/a Spoken to in one's language65% (94)45% (268) Had a birth companion59% (85)40% (238) Chose one's birth position19% (28)24% (138) Use of preferred clothing63% (91)20% (119)

17. Contribution Testing the construct of D&A in a Latin America context (rural, hard-to-reach) – What components of the D&A construct are relevant; missing in context of rural Guatemala – What are the contributors to and consequences of experiencing and perceiving D&A in this context? Consider relationship between D&A and ‘respect- promoting’ practices Contribute to measurement lessons: training local data collectors, adapting tool in a local language; data collection in remote areas; measurement as an intervention

18. Acknowledgments TRAction Guatemala team based at the URC office in Guatemala, Hernán Delgado (PI) Implementing partner COTONEB & CHWs Field supervisors Miguel Brito and Elena Gómez Data collection teams from Ixil The families from the 15 communities who shared their time and experiences with us.