Health system bottlenecks hindering provision of supportive and dignified maternity care in public health facilities

Abstract

Mistreatment with women during childbirth is prevalent in many in low- and middle-income countries. There is dearth of evidence that informs development of health system interventions to promote supportive and respectful maternity care in facility-based settings. We examined health systems bottlenecks that impedes provision of supportive and respectful maternity care in secondary-level public healthcare system of Pakistan. Using a qualitative exploratory design, forty in-depth interviews conducted with maternity care staff of six public health facilities in southern Pakistan. Development of interview guide and data analyses were guided by the WHO’s six health system building blocks. A combination of inductive and deductive approach was used for data analyses. Our study identified range of bottlenecks impeding provision of RMC. In terms of leadership/governance, there was lack of institutional guidelines, supervision and monitoring, and patient feedback mechanism. No systematic mechanism existed to screen and record patient psychosocial needs. Health workforce lacked training opportunities on RMC that resulted in limited knowledge and skills; there were also concerns about lack of recognition from leadership for good performers, and poor relationship and coordination between clinical and non-clinical staff. Regarding the domain of service delivery, we found that patients were perceived as un-cooperative, non-RMC manifestations were acceptable and normalized under certain conditions, and restrictive policies for active engagement of companions. Finally, lack of cleanliness, curtains for privacy, seating arrangement for companion were the identified issues infrastructural issues. A service-delivery intervention package is needed that effectively uses all six components of the health system: from investments in capacity building of maternity teams to creating a conducive facility environment via proper governance and accountability mechanisms. Such interventions should not only focus on provision of maternity care in a respectful and dignified manner, but also ensure that care is responsive to the psychosocial needs of pregnant women without any discrimination.

Psychosocial support during childbirth: Development and adaptation of WHO’s Mental Health Gap Action Programme (mhGAP) for maternity care settings

“…Two trained sociologists conducted 40 interviews using an interview guide with clinical and non-clinical labour room staff as well as health managers. The existing health system’s maternity care, including psychosocial support for pregnant women, was explored through interviews [ 19 ]. The psychosocial part of the interviews explored: (i) participants’ understanding of, and current practices around, supportive care to women during labour and childbirth; (ii) the psychosocial needs of, and provision of inclusive support to, women with disabilities, mental health issues (principally anxiety and depression), or socio-demographic vulnerabilities (e.g., young age, different ethnicity, poor socio-economic status); and (iii) training that participants had received related to psychosocial support.…”

“…Interviews were conducted in Sindhi language and were recorded with participants’ consent. Data were analysed in a combination of inductive and deductive approaches described elsewhere [ 19 ]. Define: Core team reviewed existing national service-delivery guidelines for maternity care during labour and childbirth to identify respectful and inclusive psychosocial support in the labour room.…”

Understanding the Mechanisms of Change in the Supportive and Respectful Maternity Care Intervention in Sindh, Pakistan: Provider Perspectives

“…The technical content of the S-RMC training handbook drew from WHO's intrapartum care guidelines 7 and Mental Health Gap Action Programme materials for maternity settings 16 and contextual evidence. 17 Details of the intervention design, implementation, and effectiveness have been previously published. 12 , 13 A member of the existing clinical maternity team—identified as a focal person called the “mental health first aider”—was made responsible for overseeing the implementation of S-RMC components in routine intrapartum care.…”

Applying the COM-B Model to Understand the Drivers of Mistreatment During Childbirth: A Qualitative Enquiry Among Maternity Care Staff

“…[16][17][18][19][20][21] Studies have also examined the health system perspective to identify systemic factors of mistreatment during childbirth. 19,[22][23][24] Such studies 25 have identified several complex, multifaceted factors of mistreatment during childbirth, which can be classified broadly as: individual (prejudice, ensuring compliance for positive outcomes, and stress); sociocultural (normalization of mistreatment and power dynamics); and structural (workload and lack of accountability). It is worth noting that studies investigating reasons for patient mistreatment in general health care identified similar underlying behavioral drivers.…”