Promoting Respectful Maternity Care Using a Behavioral Design Approach in Zambia: Results from a Mixed-Methods Evaluation

"Given the global scale of disrespectful care, these low-cost solutions hold promise for improving the quality of care women receive during labor and delivery."

Formative research conducted through a behavioural science lens in Chipata, Zambia, demonstrated that disrespectful care during childbirth was prevalent, and providers experienced several behavioural barriers to provision of respectful maternity care (RMC). Building on these findings, the team developed and tested evidence-based, low-cost solutions to promote RMC. This study describes the participatory approach and shares findings on the impact of the resulting solution package on intermediary and final outcomes, as well as behavioural mechanisms. The aim of this research is to advance understanding of ways to address disrespect and abuse during labour and delivery and to improve women's experience of care.

As detailed here, under the United States Agency for International Development (USAID)-funded Breakthrough RESEARCH project, ideas42 developed a solution package using an iterative co-design process with a range of different stakeholders including the District Health Office of Chipata, the local team from their implementing project partner (Safe Motherhood 360+, or SM360+), the research team, midwives and their supervisors, and women in labour. The co-design process resulted in the design of a solution package consisting of 5 components:

1. The BETTER (Breathe, Encourage, Turn, Think, and Rub) pain management toolkit, which includes pain management technique posters to cue both providers and clients, a pain management manual, massage balls, and a pain management partograph guide;
2. A feedback box, which was intended to empower clients to share feedback and provide the means to regularly assess clinic performance;
3. The provider-client promise document, which was read aloud and signed by the provider and the client in an attempt to clarify and set expectations for behaviour of both and to reassure clients of the treatment they should receive;
4. Fresh start funds (5000 Kwacha, approximately $US300), which were designed to give staff a sense of agency in changing the experience of care to improve the client experience; and
5. A reflection workshop, which encouraged providers to reflect on client care, build an intention to change care as a facility, and introduce solutions.

Editor's note: Click here [PDF] to learn more about these solutions.

To test the effectiveness of the package, the researchers collected quantitative surveys from providers and postpartum clients at baseline and endline in intervention and comparison facilities. They also conducted qualitative interviews with providers, supervisors, and clients at endline and observed labour and delivery practices at intervention facilities over the course of implementation. Key findings include:

• Clients at implementation facilities were 15 percentage points less likely to experience any form of disrespect and abuse compared to clients at comparison facilities (ß = − 0.15 p = 0.01).
• Clients at intervention facilities were 33 percentage points more likely to request pain management compared to clients who delivered at comparison facilities (ß = 0.33, p = 0.003).
• Providers at intervention facilities reported greater use of more evidence-based pain management techniques at endline relative to baseline.

Among the intermediate outcomes described in the theory of change was "rapport, empathy and trust exists between provider and patient". Several clients described feeling a sense of relief at being able to expect the kind of care described in the provider-client promise. None reported that the promise had been broken during her delivery. Clients also remarked that the promise was educational and that they valued being consulted and involved.

Per ideas42, the "participatory design led to interventions which were feasible to implement without a significant investment of resources and were well-received by clients and providers."

In reflecting on the findings, the researchers note that one objective of the solutions was to expand the providers' mental model of their role to include pain management support as a means for improving client experience. Through the design process, they were able to identify a range of context-appropriate ways to give providers repeated pain management cues. The evaluation found a significant increase in providers citing pain management as a priority task, which contributed to improved pain management provision. "These findings point to strengths in the behavioral design approach, both in identifying the appropriate behavioral mechanisms to target as well as choosing effective intervention points to activate these mechanisms."

In conclusion: "The results of this small-scale study act as a proof of concept, demonstrating that the behavioral design approach can lead to solutions that show potential for impact. In other settings where providers face similar barriers to providing RMC, an adaptation of this solution package might lead to similarly positive results."

Editor's note: According to ideas42, results from this study were disseminated in a national event hosted by SM360+ with the Zambian Ministry of Health, which is considering incorporating solutions into a broader RMC policy. ideas42 is adapting this solution package to Liberia under the USAID-funded Breakthrough ACTION project; click here to learn more.