1. Reena Sethi Sr. M&E Advisor Jhpiego
Respectful Maternity Care (RMC) in Malawi: Secondary Analysis of Labor and Delivery Observations
Reena Sethi
Sr. M&E Advisor
Jhpiego

2. Presentation Outline Objectives Setting
Other studies on respectful maternity care (RMC) in Malawi
Descriptive results from labor and delivery (L&D) observations
Summary of findings
Strengths and limitations

3. Objective of the Analysis
To present the frequency of observed RMC during labor and delivery among women delivering in 40 high-volume government health facilities in Malawi through secondary data analysis

4. Setting: Malawi Population 17.4 million (2014)*
GDP: $3.68 billion (2013)*
Low income
Health indicators
Maternal mortality ratio
460 deaths per 100,000 live births
Neonatal mortality rate
25 deaths per 1,000 live births
Total fertility rate
6.0 children born/woman
Health worker density
1.39 HWs/1,000 population
*Source: CIA World Factbook (est)

5. Setting: Malawi Institutional delivery rate: 73%
71% of births attended by a skilled birth attendant
Source: Malawi DHS 2010
A Malawian mother with her two children in Mzimba District, Malawi.© 2008 Lisa Basalla, Courtesy of Photoshare

6. Previous Studies of RMC in Malawi
Seljeskog et al. 2006: Factors influencing women's choice of place of delivery in rural Malawi: An explorative study
Staff in L&D wards did not communicate and kept women waiting
Deliveries without provider assistance
Privacy was difficult to achieve
Changole et al. 2010: Patients’ satisfaction with reproductive health services at Gogo Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi
99.1% of respondents found their interaction with the provider was either good or very good
57.4% knew that it is the right of the patient to have considerate and respectful care

7. Studies of RMC in Malawi
Kumbani et al. 2012: Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi
Negative experiences of care included the following:
Provider attitudes
Delays in care
Unavailability of birth attendant
Kumbani et al. 2013: Why some women fail to give birth at health facilities: A qualitative study of women’s perceptions of perinatal care from rural Southern Malawi
Health workers shouted at them
Not always informed of findings

8. Data Source
Labor and delivery observations from Helping Babies Breathe Evaluation in Malawi (secondary data)
27 districts
40 health facilities with 5+ deliveries/day
Facility Type
Number of facilities
Number of L&D observations (all)
Number of L&D observations (first stage of labor)
Central Hospital 1
114 11
District Hospital 22
1,343
126
Health Center 16
606 67
Rural Hospital 46 4
Total 40
2109
208

9. Number of observations Frequency of occurrence
Non-Dignified Care
Number of observations
Number of occurrences
Frequency of occurrence
Provider does not respectfully greet pregnant woman
208 29
13.9%
Provider shouts, insults, or threatens the woman during labor or after
2,109 41
1.9%

10. Number of observations Frequency of occurrence
Non-Dignified Care
Number of observations
Number of occurrences
Frequency of occurrence
Provider does not encourage the woman to have a support person present during labor and delivery
208
173
83.2%
Support person or companion for mother is not present at birth
2,079
1,818
87.4%
If support person is not present at birth, support person is restricted from being present
210
11.6%

11. Number of observations Frequency of occurrence
Non-Consented Care
Number of observations
Number of occurrences
Frequency of occurrence
Provider does not ask woman (and support person) if she has any questions
208
152
73.1%
Provider does not explain procedures to woman (and support person) before proceeding
205 35
17.1%

12. Number of observations Frequency of occurrence
Non-Consented Care
Number of observations
Number of occurrences
Frequency of occurrence
Provider does not inform the woman what will happen before conducting the vaginal examination
205 42
20.5%
Provider does not inform pregnant woman of findings
200 20
10.0%

13. Non-Confidential Care
Number of observations
Number of occurrences
Frequency of occurrence
Woman does not have audio and visual privacy
208
121
58.2%
Provider does not drape woman (one drape under buttocks, one over abdomen)*
152
73.1%
*current standard in Malawi is the use of one drape

14. Non-Confidential Care
Number of observations
Number of occurrences
Frequency of occurrence
Woman does not have her own bed (not sharing)
208 5
2.4%
Provider does not use curtains or other visual barriers to protect woman during exams, births, procedures
206 54
26.2%

15. Abandonment or Denial of Care
Number of observations
Number of occurrences
Frequency of occurrence
Provider does not encourage woman to consume fluids/food at least once during labor
208 70
33.7%
Provider does not encourage or assist woman to ambulate and assume different positions at least once during labor 58
27.9%
Provider does not ask woman which position she would like to deliver in
207
194
93.7%

16. Abandonment or Denial of Care
Number of observations
Number of occurrences
Frequency of occurrence
Woman requested some pain relief for her pain but was not given anything
132 66
50.0%
Woman was not allowed to deliver in her preferred birthing position (if she had a preferred position)
273 36
13.2%
Mother and newborn were not kept in same room after delivery (rooming in)
1,781
249
14.0%

17. Number of observations Frequency of occurrence
Physical Abuse
Number of observations
Number of occurrences
Frequency of occurrence
Provider slaps, hits, or pinches the woman during labor or after
2,109 4
0.2%

18. Summary of Findings Physical abuse was rare
Provider-client communication occurred more frequently in the direction of the provider to the client and less frequently from the client to the provider
A small proportion of women had a support person present
Privacy was an issue in a majority of cases—both audio/visual privacy and personal privacy
Most women were not asked about their preferred birthing position

19. Recommendations
Reinforce RMC during BEmONC trainings and as part of quality improvement standards for labor and delivery
Include RMC in coaching and mentoring
Maternity in-charges to facilitate RMC through supervision

20. Strengths & Limitations
Direct observations may be an objective measurement method
Possible Hawthorne effect
Unable to observe all components of Rights of Childbearing Women framework
Relatively small sample size for RMC items in the first stage of labor

21. Thank you!
Malawi HBB Evaluation Team: Shivam Gupta, Abigail Kazembe, Angella Mtimuni, Reena Sethi, Lolade Oseni, Tambudzai Rashidi, Evelyn Zimba, Stella Abwao, Barbara Rawlins, Fannie Kachale