1. Measuring Prevalence of Disrespect and Abuse during Childbirth in Tanzania and Ethiopia: The Hansen Project Hannah Ratcliffe June 24, 2014

2. Partnerships

3. Study Areas Dar es Salaam, Tanzania Amhara & SNNP Regions, Ethiopia Photo credit: Brenda D’mello, CCBRTPhoto credit: Kelly Ramundo/USAID

4. Study Design Baseline study – TZ: April – August, 2013; ET: July – September, 2013 – What are types and prevalence of disrespect and abuse among women delivering in public health facilities? – What are factors associated with disrespect and abuse? Intervention Phase (ongoing) – Which locally acceptable, effective, and sustainable intervention(s) can reduce disrespect and abuse during childbirth? Evaluation

5. Research Methods Quantitative MethodTanzaniaEthiopia Exit Interviews Clients interviewed at time of discharge from facility— approximately 3-6 hours post-delivery N=2000N=204 Direct observations of client-provider interactions Clients observed throughout their time at the facility, from registration to 2 hours post-delivery N=208N=193 Community Follow-Up Interviews Mothers interviewed in their homes approximately 4-6 weeks post-delivery N=70N/A Provider Interviews Providers interviewed and completed self-administered survey on job satisfaction and perceptions of clients N=50N=30

6. Seven Categories of Disrespect and Abuse CategoryExample Physical abuseSlapping, pinching Non-consented care Absence of informed consent or patient communication, forced procedures Non-confidential care Lack of privacy (e.g. laboring in public) and/or confidentiality (e.g. disclosure of patient information) Non-dignified care Intentional humiliation, rough treatment, scolding, shouting, blaming, negative perceptions of care Discrimination based on specific patient attributes Discrimination based on race, ethnicity, age, language, HIV status, economic status, educational level, etc. Abandonment of care Women left alone during labor and birth, failure of providers to monitor women and intervene when needed Detention in facilities Detention of mother and/or baby in facility after delivery, usually due to failure to pay Bowser and Hill 2010

7. Operationalizing the 7 Categories Bowser & Hill Category Hansen Category Example Physical abusePhysical AbuseSlapping, pinching Non-consented care Absence of informed consent or patient communication, forced procedures Non-confidential care Breaches of auditory privacy, eg disclosure of patient information while others can hear Lack of privacy Breaches in physical privacy, eg laboring in public, insufficient privacy infrastructure (curtains, partitions) Non-dignified care Intentional humiliation, rough treatment, scolding, shouting, blaming, negative perceptions of care Discrimination based on specific patient attributes N/A Abandonment of care Women left alone during labor and birth, failure of providers to monitor women and intervene when needed Detention in facilities Detention of mother and/or baby in facility after delivery, usually due to failure to pay

8. Calculating Prevalence Cross-country and cross-regional comparisons using a variety of methods have yielded several lessons learned: – Context matters – Timing and setting matter – Question phrasing matters And several outstanding questions: – Whose opinion counts? – How is reporting influenced by normalization and biases?

9. Calculating Prevalence—Context Matters Type of Disrespect and Abuse Tanzania N=2000, n (%) Ethiopia N=204, n (%) Any form of disrespect or abuse292 (15) 43 (21) Physical Abuse90 (5) 1 (0.5) Non-Consented Care5 (0.3) 36 (18) Non-Confidential Care34 (2) 28 (14) Lack of Privacy37 (2) 31 (15) Non-Dignified Care125 (6) 2 (1) Abandonment154 (8) 5 (3) Detention4 (0.2) 0 (0) Differences between countries at exit interview:

10. Calculating Prevalence—Context Matters Type of Disrespect and Abuse Ethiopia Overall N=204, n (%) Amhara Region N=98, n (%) SNNP Region N=106, n (%) Any form of disrespect or abuse 43 (21)38 (39)5 (5) Physical Abuse 1 (0.5)1 (1)0 (0) Non-Consented Care 36 (18)33 (34)3 (3) Non-Confidential Care 28 (14)27 (28)1 (0.9) Lack of Privacy 31 (15)29 (30)2 (2) Non-Dignified Care 2 (1)2 (2)0 (0) Abandonment 5 (3)5 (5)0 (0) Detention 0 (0) Differences by region within countries:

11. Calculating Prevalence—Timing & Setting Matter Differences between reporting at Exit and CFU interviews: Type of Disrespect and Abuse Tanzania Exit Interview N=2000, n (%) Tanzania CFU N=70, n (%) Any form of disrespect or abuse292 (15) 54 (77) Physical Abuse90 (5) 36 (51) Non-Consented Care5 (0.3) 4 (6) Non-Confidential Care34 (2) 36 (51) Lack of Privacy37 (2) 36 (51) Non-Dignified Care125 (6) 37 (53) Abandonment154 (8) 35 (50) Detention4 (0.2) 1 (1)

12. Calculating Prevalence—Phrasing Matters Question Tanzania Exit Interview N=2000, n (%) Experienced D&AAt any point during your stay for this delivery, were you ____/ did you experience anything that ___? 292 (15) Perceived D&AOn a scale of 1-5, were you treated in a way that made you feel humiliated or disrespected? 344 (17)

13. Calculating Prevalence: Whose opinion matters? Type of Disrespect and Abuse TZ Exit N=2000 n (%) TZ Obs. N=70 n (%) ET Exit N=204 n (%) ET Obs. N=193 n (%) Non-Confidential Care34 (2) N/A28 (14)N/A Discussed personal issues in earshot of other clients 1 (0.1) ---3 (2)--- Mother’s history taking findings shared when others could hear --- 42 (20)---64 (33) Non-Consented Care5 (0.3) N/A36 (18)N/A Non-consented vaginal examination 5 (0.3) ---31 (15)--- Lack of consent for vaginal examination --- 170 (82)---132 (68) Comparing prevalence from interviews and observations:

14. Reporting: Normalization and Bias “Prevalence” from exit interview/CFU is actually reported prevalence – Reporting is as complicated and personal as the experiencing of the event Evidence of possible normalization— comparing observation and exit interviews Bias in reporting caused by: – Post-delivery factors: exhaustion, relief, etc. – Fear of retribution

15. Conclusions and Next Steps Will report “prevalence” primarily as experienced D&A from exit interviews and community follow-up Working to determine an appropriate way to calculate observed prevalence Evaluation in Tanzania will be based on community follow-up – Evaluation design in Ethiopia still pending

16. Acknowledgements John and Katie Hansen Family Foundation Tanzania Ministry of Health and Social Welfare Ethiopia Federal Ministry of Health

17. Thank You! Hannah Ratcliffe hratclif@hsph.harvard.edu www.maternalhealthtaskforce.org www.womenandhealthinitiative.org