Barriers to Provision of Respectful Maternity Care in Zambia: Results from a Qualitative Study through the Lens of Behavioral Science

"In order to change practices in the delivery room, not only must we generate a moment of reflection on current treatment practices, but we must also seek to transform the context in which providers work so that their environment emphasizes the importance of client experience of care as a core function of providers' work."

Respectful maternal care (RMC) is a key component of the World Health Organization (WHO)'s framework of quality maternal and newborn health. However, studies show that disrespectful or coercive behaviours by doctors, nurses, and midwives can be common at childbirth in many countries. This study applies a behavioural science lens to identify features of the local context that drive disrespectful and abusive care, documenting the experience of disrespectful and abusive care in Zambia, where previous work on this topic has been limited. Its purpose is to identify specific and concrete contextual cues that targeted solutions could address in order to facilitate RMC.

The researchers undertook a cross-sectional qualitative study comprising 46 in-depth interviews with key stakeholders and 9 multi-hour observations of interactions on the labour wards of 2 urban health centres in Chipata district, Eastern Province, Zambia during 2 weeks in July 2018. The interviews engaged parties with different perspectives on provider-client interactions during labour and delivery: providers, their supervisors, birth companions, women who had given birth in the last 6 months, and Safe Motherhood Action Group (SMAG) volunteers (community members who liaise between health facilities and clients in the community, often conducting outreach activities).

This process led to the identification of 5 key behavioural barriers inhibiting respectful maternity care: (i) providers do not consider the decision to provide RMC because they believe they are doing what they are expected to do; (ii) providers do not consider the decision to provide RMC explicitly since abuse and violence are normalised and therefore the default; (iii) providers decide that the costs of providing RMC outweigh the gains; (iv) providers believe they do not need to provide RMC; and (v) providers change their mind about the quality of care they will provide when they believe that disrespectful care will assist their clinical objectives. The process revealed specific features of providers' context - the environment in which they live and work and their past experiences - that contribute to each barrier. (For example, providers do not receive salient information or feedback on the impact of respectful or disrespectful care on health outcomes.) Table 2 in the paper summarises these associated contextual features and the levels at which they occur.

In discussing the findings, the researchers draw on behavioural research that points, for example, to the role of defaults in guiding behaviour, especially in situations when individuals are not consciously considering all their options before acting. For instance, if during the critical learning period of childhood, providers were not exposed to other means of correcting behaviour, they may view being stern or harsh as the best or even the only option for correcting non-compliance - in this case, with a client during delivery. (This is the availability bias.) Descriptive norms in the facility further reinforce this default as other experienced providers enact harsh behaviour and then justify it as a means to avoid client or infant death. This research suggests that, in order to promote RMC, the default means of "gaining compliance" must be shifted by reshaping the cues, including the role of peer influence, in providers' environment.

Thus, drawing from the behavioural science literature on decision-making and follow-through, this study has identified specific features in the environment of providers - whether personal experience, social norms, organisational priorities, or others - that inhibit provision of RMC. "Bringing together insights from multiple disciplines can lead to a more nuanced understanding of this challenging problem and lead to different, complementary solutions which can help transform the experience of delivery for both providers and clients."

Editor's note: A related programmatic research brief ("Enhancing Respectful Maternal Care During Labor and Delivery" [PDF], Population Council, 2019) takes the above research further and explains what the research team did to develop possible solutions to address the contextual features discovered during diagnosis. As explained here, behavioural design is an approach that leverages insights from behavioural economics, social psychology, human-centred design, and other disciplines to develop and test solutions that reshape people's environment to facilitate positive behaviour change. In that framework, the researchers developed prototypes of possible solutions and tested these with clients and providers. After 2 weeks of iterative testing and feedback, 4 low-cost, scalable prototypes were finalised:

1. Pain Management Toolkit - to incorporate the idea of pain management as part of routine client care and to give reminders to providers to use pain management techniques regularly. It includes, for example, a pain management poster (designed onsite, in local language) with mnemonic of techniques to cue providers to offer pain management.
2. Provider-Client Promise - to clarify and set expectations for behaviour (e.g, through a printed handout) on the part of both provider and client during admission and to reassure clients of the treatment they should receive.
3. Feedback Box - to empower clients to share feedback on their experience at birth routinely and provide the means to assess clinic performance.
4. Reflection Workshop - to encourage provider reflection on client care and instill a commitment to change.

Reflecting on this process, the brief notes: "The participatory nature of behavioral design offers stakeholders invested in quality improvement the opportunity to shape new solutions to positively influence provider behavior and improve the experience of care in ways that will be most effective for their settings....The insights emerging from behavioral design about barriers to respectful maternal care may be pertinent to provider behavior change interventions in other health settings and contribute to a larger body of research focused on improving the experience of care for clients."