Background

Behaviors and attitudes of maternal care providers are a major barrier to utilization of skilled childbirth care. In fact, there is growing evidence that client-perceived quality of maternal health services, particularly provider attitudes and behaviors, has a greater influence on the use of skilled care than more widely recognized factors such as access or cost. Minimizing negative provider behaviors during childbirth, including verbal and physical abuse, requires helping health personnel to explore the factors that contribute to such behaviors and develop individual coping strategies. "Staff burnout" has been documented in many high-stress clinical practice environments in both developed and developing countries.

Improving the quality of inpatient maternity care becomes increasingly important as the global guidelines for the Safe Motherhood Initiative focus more on promotion of facility-based childbirth for all women. Most safe motherhood programs train providers to improve the quality of routine maternity care and their lifesaving skills to treat obstetric and newborn emergencies.. Programs also recognize the role of "caring" behaviors in quality clinical maternity care and that core competencies for skilled providers must go beyond skills training alone to highlight the importance of "caring" as well as curing.

The CHANGE Project found a need to develop standard definitions of "maternity caring behaviors." The CHANGE Project designed a list of behaviors and tools to measure caring behaviors of individual midwives and other skilled providers during labor and delivery in a facility setting. The Maternity Care Provider Caring Behavior Assessment tool helps managers, supervisors, external observers or the providers themselves assess, address and improve maternity care provider behaviors during labor and delivery.

These caring behavior assessment tools were pre-tested in Kenya and Bangladesh with the assistance of maternal health program planners, educators, hospital supervisors, and obstetric practitioners. Their input and the pre-test results helped to refine and improve the draft tools, and to adapt the models to local contexts.

Objectives

The objectives of this activity were to:

• Define a standardized set of ideal maternity provider "caring" behaviors during labor and delivery that could be easily adapted to reflect local maternity care settings and cultures;
• Design and test a provider behavior assessment format that allows external measurement of caring behaviors; and a self-assessment tool for use by midwives;
• Create a tool to help maternity care providers respect differences between Western medical and traditional cultural obstetric practices; and
• Increase the participation of maternity care providers in the design, adaptation and implementation of the assessment tools.

Setting

The provider behavior assessments were conducted in rural and urban maternity centers in Kenya and Bangladesh. In each country, participants and partners identified facilities with a high number of births that were representative of typical maternity care settings.

In Kenya, the team chose two public facilities as pre-test sites, one urban and one rural. The urban site is a large maternity hospital in Nairobi, one of the busiest hospitals in Africa. It is a teaching center and manages some 22,000 births a year. The rural district hospital also has a high volume of maternity patients, but compared to the urban site, equipment and supplies are limited and the infrastructure is in need of repair.

In Bangladesh, the team selected four facilities to represent urban, rural, private and public maternity care environments. The public urban hospital, the largest pretest site, serves as a training institute and manages 6,500 deliveries annually. The private urban facility and the two rural facilities serve a smaller number of obstetric patients, typical in a country such as Bangladesh where utilization of facility-based obstetric care is low. Each of the four pre-test facilities manages routine delivery as well as other types of obstetric cases, including surgical cases.

The team organized the behaviors into eight categories:

1. Attend to Physical Needs
2. Be Accessible to Patient
3. Attend to Emotional Needs
4. Respect Human Dignity /Rights
5. Inform/Explain/Instruct
6. Involve Family
7. Incorporate Cultural Context
8. Minimize Negative Behaviors

The provider-client maternal provider caring behavior assessment tools consists of: 1) the maternity care provider "caring" behavior observational assessment tool; 2) the maternity care provider "caring" behavior self-assessment tool; 3) the provider focus group discussion (FGD) guide; and 4) the patient exit interview guide, 5) two user's guides for the assessment tool, one for program managers and the other for the observers, and 6) several tools for collecting and tallying basic data about the labor and delivery facility where the assessment is conducted.

These tools are used to collect data to help assess provider behaviors in several ways.

The maternal provider "caring" behavior assessment tool provides: background information and clinical data on a patient in labor/delivery and basic information on the clinical setting on the labor and delivery unit (type of staff present, patient-to-provider ratio, number of students present). This information can influence the ability of providers to care for patients.

The maternal provider "caring" behavior self-assessment tool is a list of 97 provider "caring" behaviors. In the self-assessment, individual midwives and other maternity care providers rate their own performance in caring behaviors and provider/client interaction. This information is compared to the external observer's assessment of that provider's performance.

The maternal provider focus group discussion (FGD) guide can be used after the external provider behavior assessment and the self-assessment have been completed. The maternal providers who participated should discuss the assessment activities. The facilitator can present a brief description of the results so participants have an opportunity to comment on aspects of provider behaviors that cannot be observed. For example, providers could discuss the most important behaviors, the easiest behaviors to perform, which behaviors would be easiest to improve, and the resources they need.

The patient exit interview guide can be used with patients and their families as they leave the labor and delivery unit. Their perspective on providers' behaviors can be compared with the actual observations so that facilities can monitor progress and respond to client's needs.

The program managers' user's guide for the assessment tool helps to familiarize the manager or labor and delivery unit supervisor with the overall process of improving provider behaviors and how the assessment activity fits in to the complete intervention. The observers' user's guide for the assessment tool is more focused on providing an in-depth understanding of how to perform the assessment and record the results.

The tools for collecting and tallying data about the labor and delivery facility can be used on the day of the assessment and over a longer time period; for example, number of normal deliveries in the unit each month, proportion of obstetric complications treated, or number of patients admitted on that particular day. This data can help to analyze and understand system factors that may influence assessment results in a given facility.

Adapting and pre-testing the draft assessment tools in Kenya and Bangladesh

The "caring" behavioral guidelines recommend broad categories of behaviors. The specific categories and behaviors that are appropriate and acceptable in the sociocultural context of each area must be negotiated locally.

Working with midwives, physicians and other maternal health and survival program planners and policy makers in Kenya and Bangladesh, CHANGE adapted the behaviors and assessment tools to reflect local maternity care settings and program needs in the two country settings. These sets of locally appropriate maternity care provider "caring" behavior assessment tools were adapted and pre-tested in each country.

The key elements of the adaptation and pretest process implemented in Kenya and Bangladesh were:

• Key informants adapted the tool for their facility/country settings;
• Key informants suggested ways to use the tool in future activities to improve providers' caring behaviors;
• Facilities appropriate for testing the tool selected;
• External (consultant plus local counterpart) assessment/observations conducted of provider-patient interactions in Labor/Delivery Unit; and
• Provider self-assessments, focus group discussions, and patient exit interviews conducted.

Focus Group Discussions (FGDs) with Maternity Care Providers: Negotiating Caring Behaviors with Skilled Providers

Following observations, focus group discussions were conducted with five to six nurse-midwives working in the labor and delivery units. The team conducted one focus group discussion in the rural Kenyan facility and two in Bangladesh, one each in the urban public and rural private facilities.

Participants reviewed the list of caring behaviors and discussed which caring behaviors they thought were more important and why. They also talked about which of the caring behaviors were the easiest to perform, which were most difficult and which caring behaviors they would be willing to incorporate into their routine maternity care provision.

Findings

The combined results of the assessments provided the basis for design of a set of locally appropriate provider behavior change interventions.

In the African and Asian settings, pre-tests showed that after local adaptation, the draft tool was a simple, user-friendly way to document provider "caring" behaviors through observation. Almost universally, providers and planners recognized the behaviors as essential, if frequently overlooked, aspects of quality maternity care during labor and delivery. Participants welcomed the lists of caring behaviors as aids to assist in integrating the "caring" behavioral aspects of obstetric care into provider training programs.

During the pretests, observational methodology also allowed an opportunity to assess routine clinical care during labor and delivery. Many of the obstetric care providers involved in developing and refining the local versions of the assessment tools felt strongly that it was necessary to add a section on the assessment tool to record the frequency of performance of several aspects of routine monitoring of delivery care. The final versions provide space to record timing and frequency of monitoring of blood pressure, fetal heart, cervical dilation, status of membranes and fluid and urine output.

Pre-testing the tool in different country settings and different types of facilities revealed wide variations in the amount and types of caring behaviors provided to patients. Caring behaviors categorized as attending to women's emotional needs were the most frequently observed in both countries. Observing and talking to patients was the most common caring behavior performed by providers in Kenya. Touching and demonstrating caring were more common in Bangladesh. Advising patients on their breathing and positions of comfort, under the category of "inform, explain, instruct" was the second most common behavior in both countries. These behaviors were also rated among the most important and easiest to perform by nurse-midwives in both countries.

Behaviors from the two categories ‘Incorporate cultural context' and ‘Involve the family' - essential elements of patient-perceived quality of obstetric care - were infrequently observed in both country settings. Although the sample of providers observed was small, these two important aspects of provider behavior during labor and delivery were not a routine part of facility-based childbirth practice.

Although very few ‘negative behaviors' were observed during the assessments, their absence did not guarantee a "caring" obstetric environment.

More work needs to be done to explore the reasons why caring behaviors are not more routinely practiced as part of facility-based care even in settings where no obvious external barriers are evident. Documenting medical, system and policy barriers that discourage providers from incorporating "caring" behaviors into their patient care, as well as investigating "internal barriers" from the provider perspective are first steps toward eliminating these barriers and strengthening the "enabling environment" required for skilled maternity care providers to perform effectively. For example, almost all of the pretest sites had a "no visitor" policy in place in the labor and delivery unit. Policies and protocols that negatively affect provider performance of caring behaviors can be changed if there is sufficient motivation to do so. For example, in Zambia, a pilot program that changed family visitation policy to allow family members on labor and delivery wards was well received by both families and maternity care providers.

Program Implications

The information gathered from the provider-client behavior assessment tools can be used to:

• Determine the amount and quality of caring behaviors that are part of current maternal provider's practice during labor and delivery;
• Elicit provider perceptions of the content and quality of their caring behaviors, and interaction with patients and families during labor and delivery;
• Provide insights into barriers to improved provider behaviors, as well as potential motivating factors and resources needed to promote provider (and client) behavior change;
• Document the clients' point of views; and
• Develop an evidence-based, participatory plan to improve the behaviors of maternity care providers during labor and delivery.

The tools can be used at the national, district hospital, and/or health center level.

• Program planners can use the tools to design strategies and interventions on a larger scale to improve the behaviors of maternity care providers during labor and delivery.
• Midwifery educators/tutors can use the tools to serve as practical behavioral guidelines to strengthen the pre-service behavioral training of midwives and other maternal health care providers.
• Training coordinators can use the tools in a similar way as a part of ongoing in-service educational activities.
• Supervisors of labor and delivery units can use the tools to help assess the content and quality of their staff's behaviors on the job.
• Management can use it as a supervisory tool to provide an objective basis to demonstrate improvements in client/provider interaction and maternity care provider behaviors.

Next Steps

The initial responses of key maternal health professionals and program planners who participated in the design and pre-testing of the tools in Kenya and Bangladesh were positive. They made suggestions to revise the design, content and use of the draft tools, and suggested additional activities:

• Incorporating the core "caring" behaviors into a set of standards and guidelines to be used as part of pre-service training for midwives and other cadres of skilled childbirth attendants;
• Closely linking the standards for caring behaviors contained in the assessment tools with the basic standards of quality care for routine childbirth and obstetric complications;
• Conducting the caring behavior assessments on a larger scale, implementing workshops for providers to analyze the assessment results and developing participatory action plans to improve caring behaviors; and
• Utilizing an operations research methodology to determine if the assessment and follow-on activities were effective to improve provider behaviors.

Conclusions

Increasing the use of skilled childbirth care is a goal to improve maternal and newborn survival and a key indicator in measuring the success of country programs. Planners increasingly recognize the importance of "caring" behaviors as part of patient-perceived quality of obstetric care. Pretest results for the maternity care provider "caring" behavior assessment tool demonstrated that there is still a long way to go to assure that the "caring" that all women expect and deserve as part of their childbirth experience is routinely available to them.

Nonetheless, the pre-tests suggested that full-scale use of the tools in individual facilities or national programs can help develop a systematic, multi-level set of behavior change interventions to increase provider caring behaviors during facility-based births. The assessment tools provide a foundation to develop behavior-based, research-based interventions to increase use of skilled obstetric care.

In addition to addressing individual provider behaviors, changing social norms related to "caring" in obstetric care and toward violence against women in obstetric and other settings is also essential. Placing "caring" obstetric practice high on the agenda at national policy level, and integrating sensitization about "caring" issues into all aspects of maternity care provider training is key. The training of maternity care providers must support compassionate care for patients. Identifying key individuals who can speed the diffusion of ideas to change medical norms and culture.

Programs can contribute to changing provider behaviors and increasing utilization of skilled childbirth care by all women for conducting a participatory analysis of assessment results to help providers to:

• Understand the internal barriers contributing to lack of caring;
• Identify and address external system, medical and policy barriers that inhibit enabling obstetric practice environments; and
• Change social norms regarding the medical importance of "caring" in a facility-birth environment, and toward violence against women overall.

Adaptations and Future Uses of CHANGE Tools and Approaches

• Maternity care providers and health system planners are using the tools to develop behavior-based strategies and training programs to improve provider "caring" behaviors.
• Family Care International (FCI) developed a modified caring behaviors assessment tool and a three-hour "caring behaviors" session to add to their Skilled Care Training.
• The American College of Nurse Midwives (ACNM) is developing a module on caring behaviors to add to their Lifesaving Skills (LSS) Manual.
• The University Research Corporation (URC), as part of their Quality Assessment Program, is developing an intervention to improve provider caring behaviors during labor and delivery and a set of provider caring behavior monitoring and evaluation tools.

Tools (Skilled Provider Plus)

Report