1. INTERVENTIONS TO PROMOTE DIGNITY IN CHILDBIRTH- HESHIMA PROJECT Charity Ndwiga, Charlotte Warren, Lucy Kanya, Timothy Abuya, George Odhiambo and Alice Maranga RMC meeting 24 th June, 2014

2. Heshima Project Objectives 1.Specify types and prevalence of D&A 2.Develop and validate tools for assessing D&A 3.Identify potential drivers of D&A 4.Design, implement and evaluate interventions to reduce D&A 5.Generate lessons for replication and scale up

3. Stakeholder engagement Intervention suggestions

4. Package of interventions to promote dignity in childbirth

5. Policy Engagement with MOH In depth interviews with DHMT Steering committee meetings Facility In depth interviews with facility staff Service statistics NNAK reports Project staff observations Community FGDs with men and women previously empowered their rights and obligation during childbirth CHEWS/ CHWs FIDA reports Project staff observations Endline Survey Scale up plan Observations, Exit interviews Provider interviews IDIs FGDs Intervention design Stakeholder Engagement Baseline Survey Formative Research Definition of Disrespect and Abuse Landscape analysis Planning and development Implementation research Quarterly Measure  Analyze  Improve  Sustain Heshima Project

6. Policy level activities Developed the intervention package- provider and community- draft RMC Tool Kit in place Participate in Maternal Health Bill process Working with professional bodies, MOH and policy makers, parliamentarians to establish mechanisms for transparency and accountability at all levels- on going Supporting MOH and Partners in scale up

7. Facility level interventions ElementsFocus Values clarification and attitude transformation (VCAT) Improve knowledge on RMC, D&A and health as a human right for both clients and providers Improve self awareness on how socio norms, values, attitudes and behavior affect care Support individuals and facilities to cultivate professionalism & mutual respect among themselves, clients/relatives and communities Quality Improvements Teams (QITs) Improve individual and team accountability at providers and managers levels Maternity Open Days/ Caring for carers Mechanisms to strengthen interpersonal interactions, discuss ways to deal with drivers of D&A and improve care and working conditions

8. Values clarification and attitude transformation (VCAT) VCAT training helps individuals to explore and honestly acknowledge what one truly values at a point in time in life in order to enrich their awareness of their own values Our values are shaped by beliefs and attitudes. Everyone has a right to her or his own beliefs Health providers have a professional obligation to give care in a respectful and nonjudgmental manner VCAT training is aimed at helping maternity providers adapt caring behaviors and professionalism

9. Results and lessons learnt 132 maternity providers from 13 study sites trained VCAT is a good tool for attitude change but requires individuals to take personal responsibility and commitment in aspiring to change Providers’ attitude and teamwork improved: “…since the VCAT training some providers have become good role models in attitude and behavior change” (Hospital Manager) Community members reported reduction in both physical and verbal abuse in almost all sites

10. Caring for the Carers Maternity providers experience work related stress due to high workload, lack of professional support and poor teamwork “..when you report on duty you work without a break... there is no way you can leave a mother in a critical time of need you just continue working” (a hospital midwife) Caring of the carers is an approach that was tested to support group and individual counseling sessions for health facility staff Aimed at preventing development of adverse reaction and reduces unnecessary psychological after effects work related stress Individuals who require more counseling are offered additional opportunities for one–on-one sessions

11. Results and lessons learnt Over 130 maternity care providers met to discuss traumatic events or critical incidents - work related stressors Caring of the carers is most appreciated among activities aimed to address D&A at providers level “These debriefing sessions make us feel that it is not about achieving targets for skilled birth attendants but someone also cares for us” (provider in maternity unit ) Can easily be adapted and replicated within the existing MOH structures

12. Maternity open days Maternity open days are one of the tested interventions aimed at promoting dignity in childbirth Community members visit maternity units to get information on labor and delivery procedures and demystify common myths and perceptions A suitable date for the open day is identified and invitations sent through the existing community information systems Privacy and confidentiality for mothers in labor during the visits is maintained

13. Results and lessons learnt Maternity open days improve knowledge on labour and delivery A promising intervention in clarifying misconceptions and myths associated with facility based childbirth “... I have seen... there no ropes to tie one to the delivery bed during childbirth...” (primigravida after maternity open day)

14. Alternative Dispute Resolution: Mediation A dispute resolution mechanism process where an independent and impartial third party (mediator) facilitates a negotiation process between disputing parties Decisions are made by the parties themselves with facilitation from the mediator Adapted from FIDA –mainly used for land disputes and family cases FIDA trained CHWs and society leaders on mediation; managers and providers also orientated

15. Key observations V CAT training increases providers’ responsiveness to dignity of care Providers need knowledge on client’s rights and professional ethics for improved accountability Maternity Open Days - a promising intervention to demystify labor and delivery procedures Caring of the carers is good approach to support providers with work related stress and therefore deals with drivers of D&A Intervention could be attributed to increased SBA and a supportive working environment for providers

16. Acknowledgments USAID through TRAction Project/ URC MOH: DFH, RMHSU, Research Unit, Nursing and Midwifery Unit Standards and Regulatory Services Unit National Nursing Association of Kenya – Midwifery Chapter Federation of Women’s Lawyers Kenya (FIDA) Nursing Council of Kenya, KMA, COC Kenya Obstetric and Gynecological Society UON, OBGYN, Schools of PH, and Nursing Practicing private and public representatives White Ribbon Alliance – Kenya Health Rights Advocacy Forum (HERAF) Study site communities, providers and managers

17. Photo by Flynn Warren courtesy of the Population Council The Population Council conducts research and delivers solutions that improve lives around the world. Big ideas supported by evidence: It’s our model for global change. © 2014 The Population Council, Inc. Photo by Richard Lord courtesy of the Population Council Ideas. Evidence. Impact.