1. MEASURING PREVALENCE OF D&A DURING CHILDBIRTH IN KENYA: THE HESHIMA PROJECT Timothy Abuya, Charity Ndwiga, Lucy Kanya, George Odhiambo, Alice Maranga and Charlotte Warren Respectful Maternity Care Seminar: 24 th June 2014 George Washington University School of Public Health

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. Why measure the prevalence? Is the measurement aimed at developing interventions/policy response at both global and local levels? – Developing interventions to improve quality of care – For advocacy purposes to bring forth human right issues of equity/access to quality health care – Improve health indicators (maternal indicators) Is it aimed at developing tools that are sensitive enough to help point the magnitude of the problem (academic purpose) ?

4. How purpose influences measurement approach PurposeThings to consider for measurement developing interventions/policy response at both global and local levels? Multiple sources of data that are cost effective -take account of client’s perspective developing tools that are sensitive enough to help point the magnitude of the problem -Rigorous and multiple sources of data to triangulate /sensitivity of the measurement tools -Huge sample size in multiple places to account for variations in context -standardization of tools-language and whether to use single or multiple item response

5. Defining disrespect and abuse in facility-based childbirth Structural level: What women and providers consider poor care, but is caused by system deficiencies Deviations from national standards of good quality care Deviations from human rights standards (available, accessible, acceptable, quality) Individual level: Normalized D&A: What women experience as D&A but providers consider normal When providers are disrespectful and abusive but women consider it normal Individual level: actions that all agree are D&A Initial intervention targetPrevalence MeasurePolicy Advocacy Structural level: System deficiencies that lead to poor care that is accepted and normalized Individual level Structural level Policy Level

6. Multiple data sources for different needs PurposeData sources developing interventions/policy response at both global and local levels Client provider observations client exit interviews (Immediate/follow up) Inventories Provider/community views developing tools that are sensitive enough to help point the magnitude of the problem Client provider observations client exit interviews (Immediate/follow up) Community survey Provider/community views Case narratives

7. From the bull’ eye to the actual measurement CategoryExperienced by clients Non confidential care Treated in a way that violated privacy and/or confidentiality Non-dignified care Provider said/used a facial expression that made you feel uncomfortable Neglect/ abandonment Left unattended when needed help Requests for pain relief ignored Non-consented careTreatment given without permission Physically abusedSlap, pinch, push, beat, poke Inappropriate demands for payment Detention for failure to pay Request for a bribe for services

8. Any occurrence of Disrespect and Abuse Main question: at any point during labor and delivery were you treated in a way that made you feel humiliated or disrespected 20% clients (n= 641) reported they were made to feel humiliated or disrespected at some point during labour and delivery

9. Type of D&A Experienced by Postpartum Women

10. Comparison of occurrence of any D&A with socio economic status % reportingLowest 20%OthersP value Any D&A 24.2%19.1%0.197 Lowest 40%Other categories 21.9%19.0%0.367 Lowest 60%Other categories 20.6%19.5%0.729 Highest 20%Other categories 15.5%21.3%0.143

11. Comparison of highest and lowest quintiles and D&A experience

12. Factors associated with D&A Characteristic Any D&ADetained Request for bribe Parity: ref: no previous children Between 1-3 children 1.2(0.59,2.3) p=0.621 3.5 (2.2, 5.9) p<0.001* 4.5 (1.2,17.4) p=0.028* Between 4-9 children 0.9 (0.13,6.8) p=0.984 12.4 (3.2 47.4) p<0.001* 49.4 (8.6,279) p<0.001* Marital Status (ref: Never Married & Separated) Currently Married 0.7 (0.42,1.0) p=0.067 0.2 (0.1,0.34) p<0.001* 0.2 (0.1,0.72) p=0.014* Age: (ref below 19 years) 20-29 years 1.1 0.61,1.8) p=0.818 0.4 (0.12,1.4) P=0.186 0.4 (0.092,1.7) p=0.223 Over 30 yearsNA 0.3 (0.03,1.8) p=0.185 NA

13. Prevalence of D & A observed during admission and delivery

14. Methodological issues to measurement What is the best methodological approach to assess the prevalence of D&A? - Different methods yield different estimates of prevalence of D&A? -Method for assessing the prevalence depends on purpose - Key considerations are likely to be- logistical issues of collecting data, cost implications versus propose (policy change/interventions )

15. Other attempts made to validate the tools StudySites and magnitude Validation of Skilled birth attendance tool at facility and community follow up Two sites in Kenya-Kiambu and Kisumu (nearly 600 women observed, interviewed on exit and will be followed up this year) Assessing the impact of voucher on reproductive health behaviors Over 3000 women interviewed during end line community survey across five counties Base line community survey of a Kenya Signature program About 3000 women interviewed in Bungoma County

16. Lessons learnt Choice of data collection procedures linked to purposes-costly and cumbersome (standardizing approach/checklist, level of sensitization of data collectors) Contextualizing certain actions/observable behavior into categories that are measurable is difficult Some aspect of D&A are largely considered quality of care issues- but not written in standards of care guidelines Measurement of various categories of D&A appears to occur at various birthing stages thus difficult to have one single measure of prevalence

17. 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. Ideas. Evidence. Impact.