Respectful Maternity Care: What to measure and how to measure it

Eva Bazant, DrPH, MPH Sr. MER Advisor, Jhpiego Jennifer Huang, Jhpiego
FIGO Africa Regional Conference of Gynecology and Obstetrics Addis Ababa, Ethiopia October 25, 2013

Outline
7 Domains of RMC FIGO Code of Ethics Disrespectful behavior among providers Suggested indicators for RMC Use of monitoring and evaluation (M&E) Data sources

Respectful Maternity Care

Dignified care Consent Confidential care Non-abandonment of care No physical abuse No abuse related to cost, including detention Equity in access
Adapted from Bowser, D., Hill, K. 2010. Exploring evidence for disrespect and abuse in facility-based childbirth: Report of a landscape analysis. Harvard School of Public Health University Research. http://goo.gl/0NQ122 (Accessed Sept 22, 2013).

Professionalism in health care of women is the means by which physicians provide ethical care that respects the sexual and reproductive rights of women.
The FIGO, Code of Ethics

FIGO Medical Code of Ethics: Guiding Principles

PRINCIPL E DEFINITION
Maximize the best health outcomes

LINK

TO

RMC

Beneficence Nonmaleficence Autonomy

Dignified care, RMC as a larger part of quality of care framework No physical abuse, ensures the safety of women, Nonabandonment of care Consent and information exchange for informed decision-making, confidential care

Do no harm

Ensure rights of persons to make informed choices about their own health care

Justice

Distribute the burdens and benefits of new or experimental treatments equally among all groups

Equity in access, No abuse related to cost including detention

Respectful Maternity Care why does it matter?

Reputation and Professionalism Quality of Care Patient Safety, Service Use and Health Outcomes Provider Satisfaction and Retention

Behavior among Provider Teams

Disrespect is a threat to

patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practice.
(Leape, et al. 2012)

Six Elements of Disrespect

1. Disruptive behavior 2. Humiliating/demeaning treatment of nurses, residents and students 3. Passive aggressive behavior 4. Passive disrespect 5. Dismissive treatment of patients 6. Systemic disrespect
Leape, L. L., Shore, M. F., Dienstag, J. L., et al. 2012. A culture of respect, part 1: The nature and causes of disrespectful behavior by physicians. Academic Medicine, 87(7), 845-852.

Logic Model/M&E Framework

Context Inputs/ Activities Outputs Outcomes Impact

ANC
Labor and Delivery 7 RMC DOMAINS Care after Birth

Before

After

Illustrative Indicators for RMC

Number of women who were asked their preferred birth position Number of women who had a companion present in labor or delivery Number of women able to explain the reason for receiving a treatment for complication (cesarean section, episiotomy, etc.) Number of women who were draped during examinations Number of staff who rate the work environment as respectful

Suggested Indicators for RMC

Number of women who were asked their preferred birth position Number of women who had a companion present in labor or delivery Number of women able to explain the reason for receiving a treatment for complication (cesarean section, episiotomy, etc.) Number of women who were draped during examinations Number of staff who rate the work environment as respectful

Measuring the Indicator Before and After

Context Inputs / Activities Outputs
Number of providers trained to meet RMC competency standards in simulation

Outcomes

Impact
Number of clients intending for future births at the facility Number of women who returned for postnatal care (PNC)

Protocol for obtaining patient consent exists

Labor and Delivery Number of women able to explain the reason for receiving a treatment

Before

After

What sources should be used to collect data on RMC?

Data Sources
Data obtained from client or community Exit interviews with clients Companion interviews Community interviews including community health management board and focus groups Formal evaluations Document review Facility readiness checklist Training records and competency assessments Supervision checklist Labor & Delivery provider interviews Observation of labor and births (by 3rd party, trained observers or supportive supervisor/mentor) Service data from health information systems (HMIS) and registries

How can these data sources be routine?

1. Include sources in the work plan and budget 2. Data collection by local organizations, local universities, or facility community boards 3. Have short checklists and tools 4. Feedback via mobile phone data/SMS (anonymity ensured by 3rd party)

Key Points
The 7 RMC domains align with the FIGO Medical Code of Ethics Listen to patients/clients AND providers Select priority aspects of RMC for your context and track indicators at the levels of policy, outputs and outcomes Consider data sources that can be made routine and collected within the budget

Thank you!