Measuring Prevalence of Disrespect and Abuse during Childbirth in Tanzania and Ethiopia:

The Hansen Project

Hannah Ratcliffe June 24, 2014

Partnerships

Study Areas

Dar es Salaam, Tanzania Amhara & SNNP Regions, Ethiopia

Photo credit: Brenda D’mello, CCBRT Photo credit: Kelly Ramundo/USAID

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

Research Methods

Quantitative Method Tanzania EthiopiaExit InterviewsClients interviewed at time of discharge from facility—approximately 3-6 hours post-delivery N=2000 N=204

Direct observations of client-provider interactions Clients observed throughout their time at the facility, from registration to 2 hours post-delivery N=208 N=193

Community Follow-Up InterviewsMothers interviewed in their homes approximately 4-6 weeks post-delivery N=70 N/A

Provider InterviewsProviders interviewed and completed self-administered survey on job satisfaction and perceptions of clients N=50 N=30

Seven Categories of Disrespect and Abuse

Category ExamplePhysical abuse Slapping, 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 careWomen 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

Operationalizing the 7 Categories

Bowser & Hill Category

Hansen Category Example

Physical abuse Physical Abuse Slapping, pinching

Non-consented care

Non-consented care

Absence of informed consent or patient communication, forced procedures

Non-confidential care

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 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

Abandonment of care

Women left alone during labor and birth, failure of providers to monitor women and intervene when needed

Detention in facilities

Detention in facilities

Detention of mother and/or baby in facility after delivery, usually due to failure to pay

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?

Calculating Prevalence—Context Matters

Type of Disrespect and AbuseTanzania

N=2000, n (%)Ethiopia

N=204, n (%)Any form of disrespect or abuse 292 (15) 43 (21)

Physical Abuse 90 (5) 1 (0.5)

Non-Consented Care 5 (0.3) 36 (18)

Non-Confidential Care 34 (2) 28 (14)

Lack of Privacy 37 (2) 31 (15)

Non-Dignified Care 125 (6) 2 (1)

Abandonment 154 (8) 5 (3)

Detention 4 (0.2) 0 (0)

Differences between countries at exit interview:

Calculating Prevalence—Context Matters

Type of Disrespect and Abuse

Ethiopia Overall

N=204, n (%)

Amhara Region

N=98, n (%)

SNNPRegion

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) 0 (0) 0 (0)

Differences by region within countries:

Calculating Prevalence—Timing & Setting Matter

Differences between reporting at Exit and CFU interviews:

Type of Disrespect and Abuse

TanzaniaExit InterviewN=2000, n (%)

TanzaniaCFU

N=70, n (%)

Any form of disrespect or abuse 292 (15) 54 (77)

Physical Abuse 90 (5) 36 (51)

Non-Consented Care 5 (0.3) 4 (6)

Non-Confidential Care 34 (2) 36 (51)

Lack of Privacy 37 (2) 36 (51)

Non-Dignified Care 125 (6) 37 (53)

Abandonment 154 (8) 35 (50)

Detention 4 (0.2) 1 (1)

Calculating Prevalence—Phrasing Matters

Question

TanzaniaExit InterviewN=2000, n (%)

Experienced D&A At any point during your stay for this delivery, were you ____/ did you experience anything that ___?

292 (15)

Perceived D&A On a scale of 1-5, were you treated in a way that made you feel humiliated or disrespected?

344 (17)

Calculating Prevalence: Whose opinion matters?

Type of Disrespect and Abuse

TZ ExitN=2000

n (%)

TZ Obs.N=70 n (%)

ET ExitN=204

n (%)

ET Obs.N=193

n (%)Non-Confidential Care 34 (2) N/A 28 (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 Care 5 (0.3) N/A 36 (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:

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

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

Acknowledgements

• John and Katie Hansen Family Foundation

• Tanzania Ministry of Health and Social Welfare

• Ethiopia Federal Ministry of Health

Thank You!Hannah Ratcliffehratclif@hsph.harvard.edu

www.maternalhealthtaskforce.org

www.womenandhealthinitiative.org