Womens

ra+ngs of the experience of delivery care: Household survey ndings from Nairobis informal se>lements
Global Maternal Health Conference 2013
Arusha, Tanzania

Dr. Eva Bazant

Sr. Monitoring, Evalua+on and Research Advisor, Jhpiego

Background
Skilled birth a-endance is <50% for most countries in South Asia and Sub-Saharan Africa. (UNFPA State of Worlds Midwifery 2011) Prior studies: women an+cipa+ng poor treatment were deterred from birth in facili+es or reaching referral hospital
(References slide)

Focus on human rights sexual, reproduc+ve, maternal (IPPF 1996) Increasing a>en+on to private sector: focus on services oered and groups served
(Brugha, 2003, Parkhurst, 2005)

Urbaniza;on: By 2030, half of residents of Sub-Saharan Africa will be urban

(UN, Pop. Division 2006)

Objec+ves
1. To describe ra+ngs of womens delivery care experience in health facili;es in Nairobis informal se>lements
Explore dierences by facility type

2. To examine factors associated with delivery care empathy related to womens and service characteris+cs
Explore dierences by complica+ons status

Guiding Framework

Interac+on with Client

Methods

Household Survey
Study of African Popula;on and Health Research Center (APHRC) and World Bank (2006) in demographic surveillance area Maternal Health: care seeking behavior and u;liza;on for antenatal and delivery care complica+ons, expenditures Sample: All women who had pregnancy outcome in 2004-2005 Response rate 84% Sedng:

Korogocho: Older and more stable se>lement, 12 km from city center, higher popula+on density, near a municipal waste site, has higher infant and under-5 mortality rate than Viwandani Viwandani: Se>lement near the industrial area, 7 km from center

This analysis: Inclusion criteria: women who delivered in health facili;es in order to study womens experience with facility-based birth (n=1,266 out of 1,926)
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excluded 81 women found delivered in sedng led by tradi+onal birth a>endant (TBA)

Outcomes: delivery care experience (1)

9 items - Informed by qualita+ve literature review and by advisors in Bal+more and Nairobi Nega;ve aspects Posi;ve aspects leM alone for long periods Woman received adequate of +me privacy during examina+on; scolded or shouted at in provider explained health labor status; Was told an oensive provider listened to her comment (insult) related to ques+ons or concerns; sexual behavior provider oered slapped in labor. compassionate care; genuine interest in her well being.

Outcomes: delivery care experience (2)

Response Scales Likert-type response scale of Strongly Agree, Agree, Disagree, or Strongly Disagree. Unsure was recoded as the middle value, 0. Items were recoded from -2 to 2; higher score= be-er quality. Nega;vely worded items were reverse-coded.
Disagree=higher quality

For descrip+ve analysis: dichotomized responses

Outcomes: delivery care experience (3)

Factor analysis can help determine empirically how many constructs or latent factors underlie a set of items, and their meanings. Step 1. principal components analysis (PCA) in our data, PCA
suggested 2 components

Step 2: exploratory factor analysis (EFA) restricted to 2 factors

Want loadings to be > .40 and uniqueness values to be < .80 (3 items were removed in this step):

Step 3: conrmatory factor analysis (CFA)

Goodness-of-t sta+s+cs improved when two items were removed

Step 4: predicted factor scores for 2 factors were obtained (based on 5 items).

Outcomes: delivery care experience (4)

Quality Item Delivery Care (n=1263) In the facility, providers Explained your health status with terms that were understandable. Listened to your ques+ons or concerns. Oered compassionate care. Showed a genuine interest in your well- being. Scolded or shouted at you. (Reversed (not) Loading Loading Unique ness 0.39 0.71 0.41 0.53 0.61 Empathy outcome was standardized: mean of 0, SD ~ 1 (0.87), range (-3.22 to 1.26). Cronbachs was .56 Empathy Counseling -0.63 0.20 0.79 0.60 0.64 0.81 0.40 -0.05 0.12 -0.05

Mul+variate Analysis
Dependent variable delivery care empathy Independent variables: A) characteris+cs of women B) u+liza+on of ANC and delivery care Variables signicantly associated with delivery care empathy at bivariate level (t test) were entered to a mul+variate model Mul;variate linear regression adjusted for clustering by enumera+on area (neighborhood) checked for collinearity (vif)

Results

Where did women deliver?

10% 24% 20% 1% 3% 41% Private in se-tlements (n=793) Mission Hospital (n=51) Gov't hospital (n=394) Gov't health center (n=28) At home (n=467) TBA home/facility (n=193)

Women who delivered in Health Facility (n=1266)

Womens Characteris;cs Age: 64% age 20-29, 10% adolescents Educa;on: 64% had primary, 8% had none Married/in union: 83% Parity/Life;me number of births: 58% had 2-4 births; 17% had 5+ Occupa;on: Housework 62%; 21% trading/selling Service-Related ANC Number of Visits: over half had had 4+ ANC, 1% none Delivery care provider: 49% nurse/midwife, 51% doctor/clinical ocer

Sample Characteris+cs

Frequency of Delivery Care Experiences (1)

Posi;ve Aspects (n=1263)
Provider...

showed genuine interest oered compassionate care listened to Qs or concerns explained health status privacy during exam
0%

83% 79% 72% 86% 83%

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% Disagree % Agree

14% to 28% Disagreed

Frequency of Delivery Care Experiences (2)

Nega;ve Aspects (n=1263)
leM alone for long periods
26%

providers scolded or shouted at you providers made oensive comments

14% % Disagree 9% % Agree

providers slapped you in labor

8% 0% 10% 30% 50% 70% 90% 20% 40% 60% 80% 100%

8% to 26% agreed

Delivery Care Experiences by Facility Type

100% 90% 80% 70% 60%

Private in Se>lement (n=740) Mission (n=51) Gov't Hospital (n=393) Gov't Health Center (n=28)

% Agree

50% 40% 30% 20% 10% 0%

privacy

compassionate not leM alone care

not scolded

On 7 out of 9 items (4 items shown), private clinics in informal se>lements were rated higher than govt hospitals (p<.001)
N=1263

p<.001

p<.001

p<.001

p<.01

Independent Variables Age: 20-29 vs. <20 (ref) 30+ Life;me No. of Pregnancies: 2 to 4 vs. 1 (ref) 5 to 14 Ethnicity: Kikuyu vs. Luo (ref) Kamba Luhya Other Wealth: Quin+le 2 vs. Q1 (ref) Quin+le 3 Quin+le 4 Quin+le 5 Occupa;on: Trading/Selling vs. Housework (ref) Laborer/Other Pregnancy Inten;on: Later vs. Then (ref) Not at all Complica;on in preg. or delivery: Yes vs. .No (ref) Se-lement: Korogocho vs. Viwandani (ref) Service (ANC) (n=1247) and Delivery Delivery Care Provider: Doctor/CO vs. Nurse/Midwife (ref) Facility Type: Mission Hospital vs. Private Clinic in Se>lements (r) Government Hospital

Mul;variate Model (n=1263) Standard Coecent p-value Error 0.01 0.08 0.957 0.03 0.10 0.726 0.02 0.05 0.614 0.21 0.08 0.006 -0.11 0.06 0.084 -0.12 0.10 0.180 -0.16 0.09 0.058 -0.05 0.08 0.556 0.03 0.06 0.581 0.06 0.07 0.414 0.11 0.07 0.139 0.22 0.06 0.001 0.14 0.07 0.041 0.04 0.06 0.594 -0.11 0.06 0.071 -0.18 0.08 0.033 -0.11 0.05 0.040 -0.28 0.07 0.000 0.17 0.05 0.001 0.09 -0.50 0.10 0.07 0.395 0.000

Explored Eect Modier: Experience of Complica+ons

Complica;on Last complica+on was in pregnancy, severe Last complica+on was in delivery, severe C-sec+on Blood transfusion Suc+on Severe complica+on in pregnancy or delivery, or C-sec+on, blood, or suc+on 359 N 167 126 71 25 11 % of facility deliveries (n=1266) 13% 10% 6% 2% 1% 28%

StraLfy models by complicaLons status

Stra;ed Mul;variate Models Independent Variables No Complica;ons (n=904) Complica;ons (n=359) Coef (SE) p Coef (SE) p 0.03 0.10 0.761 0.00 0.10 0.761 Age: 20-29 vs. <20 (ref) 30+ 0.08 0.11 0.517 0.01 0.11 0.517 -0.05 0.07 0.457 0.17 0.12 0.118 Parity/Life;me No. of Pregnancies: 2 to 4 vs. 1 (ref) 5 to 14 0.09 0.09 0.332 0.18 0.001 0.46 -0.09 0.08 0.255 -0.17 0.13 0.156 Ethnicity: Kikuyu vs. Luo (ref) Kamba -0.07 0.10 0.538 -0.30 0.14 0.066 Luhya -0.19 0.10 0.051 -0.12 0.12 0.387 Other -0.08 0.10 0.438 0.00 0.12 0.955 0.03 0.08 0.768 0.08 0.13 0.571 Wealth: Quin+le 2 vs. Q1 (ref) Quin+le 3 0.05 0.08 0.576 0.11 0.15 0.461 Quin+le 4 0.12 0.08 0.115 0.08 0.17 0.658 Quin+le 5 0.24 0.07 0.001 0.14 0.14 0.336 0.18 0.07 0.027 0.04 0.12 0.725 Occupa;on: Trading/Selling vs. Housework (ref) Laborer/Other 0.06 0.07 0.452 0.00 0.12 0.926 -0.09 0.07 0.150 -0.12 0.11 0.266 Pregnancy Inten;on: Later vs. Then (ref) Not at all -0.17 0.09 0.067 -0.18 0.15 0.226 -0.29 0.08 0.000 -0.25 0.11 0.021 Se-lement: Korogocho vs. Viwandani (ref) Service-related Delivery Care Provider: Doctor vs. Nurse/Midwife 0.12 0.06 0.046 0.25 0.08 0.002 (ref) Facility Type: Mission Hospital vs. Private Clinic in 0.04 0.11 0.701 0.22 0.17 0.203 Se>lements (r) Government Hospital 0.08 0.000 0.11 0.003 -0.55 -0.35 Government Health Center -0.03 0.16 0.852 -0.20 0.40 0.617 Constant -0.04 0.21 0.835

Summary Key Messages

21% of women did not receive compassionate delivery care; 28% were lez alone this varied signicantly by facility type 14% to 28% of women in Nairobi urban se>lements disagreed with posi+ve aspects of delivery care; 8% to 26% agreed with nega+ve In mulLvariate models, holding other factors constants Higher delivery care empathy was reported by women with: highest household wealth & occupa+on of selling/trading - among mothers who did not have complica+ons highest parity -- among women with complica+ons. who reported a doctor vs. nurse/midwife as skilled birth a>endant Lower empathy was found among all women: delivering in government hospitals vs. private in se>lements and in more disadvantaged informal se-lement (Korogocho)

Implica+ons
Seek clients perspec;ve and ra+ngs Improve delivery care experience with standards- based quality assurance Iden+fy women who receive higher and lower quality experience in delivery care close the gap Research Household surveys complement other data sources Qualita;ve research can inform development and explana+on of survey ndings Validated tool with many items is needed, adapted to local context

Idea: Rapid post-delivery appraisal

Mothers report or respond to short survey on mobile phones Example of mTRAC in Uganda Through the toll free mTrac SMS Hotline, community members can report health service-related issues azer the service, including stockouts of essen+al malaria drugs in hospitals.

Study Limita+ons and Strengths

Limita;ons Cross-sec+onal survey in 2006 Short module of ques+ons on delivery care experience Experience with facility- based birth Possible Recall bias Strengths Large sample size - part of APHRC Maternal Health popula+on-based survey Household survey may overcome courtesy bias in exit interviews Informed by literature review of quality in maternal health & experts at JHSPH & in Kenya

Asanteni Thank you

Acknowledgements
Jhpiego: support to GMHC2013 Reviewers: D. Becker, V. Tripathi, B. Dao JHSPH: Disserta+on Advisor: M. Koenig, &

APHRC: hosted doctoral student intern, advice of JC Fotso

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Commi>ee: J. Bertrand, A. Tsui, D. Peters, V. Go Popula+on, Family and Reproduc+ve Health Department: Academic guidance, grants to student

Supplemental Slides

Literature Reviewed on Delivery Care Experience prior to star+ng study

Eastern Africa: Pearson and Shoo 2005 Ghana: D'Ambruoso, Abbey and Hussein 2005; Mills and Bertrand 2005 Kenya: Moore et al. 2002 Morocco: Belghi+ et al. 1998 Niger: Jare, Prual 1994 Nigeria: Osubor, Fatusi and Chiwuzie 2006, S. Africa: Jewkes, Abrahams and Mvo 1998 Tanzania: Gilson, Alilio 1994 Uganda: Amoo+-Kaguna and Nuwaha 2000; Weeks et al. 2005 La+n America: Campero et al. 1998; Miller et al. 2003

Overview of Methods to Study Client-Provider Interac+ons

Client Perspectives Household Survey Exit (at clinic) Clinic attendees outside of clinic Samples from surveillance database at household Focus Groups Sorting Exercises / Concept Mapping Ethnographic
u

Provider Perspectives u Observations Surveys Using checklists or structured guides Interviews Audio or videotapes FGDs Simulated client Review of hypothetical cases Role-playing with coached clients

Source: Bazant 2007, Adapted from Simmons and Elias, 1994

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