women's ratings of the experience of delivery care: household survey from nairobi's informal...

7/29/2019 Women's Ratings of the Experience of Delivery Care: Household survey from Nairobi's informal settlements

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Womensra+ngsoftheexperienceof

deliverycare:

Householdsurveyfindingsfrom

Nairobisinformalse>lements

GlobalMaternalHealthConference2013

Arusha,Tanzania

Dr.EvaBazantSr.Monitoring,Evalua+onandResearchAdvisor,Jhpiego


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Background

Skilledbirtha-endanceisen+ontoprivatesector:focusonservicesofferedandgroupsserved(Brugha,2003,Parkhurst,2005)

Urbaniza;on:By2030,halfofresidentsofSub-SaharanAfricawillbeurban

(UN,Pop.Division2006)


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Objec+ves

1. Todescribera+ngsofwomensdeliverycareexperienceinhealthfacili;esinNairobis

informalse>lements

Exploredifferencesbyfacilitytype2. Toexaminefactorsassociatedwithdeliverycareempathyrelatedtowomensandservice

characteris+cs

Exploredifferencesbycomplica+onsstatus


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GuidingFramework

Interac+on

withClient


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Methods


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HouseholdSurvey

StudyofAfricanPopula;onandHealthResearchCenter(APHRC)andWorldBank(2006)indemographicsurveillancearea MaternalHealth:careseekingbehaviorandu;liza;onfor

antenatalanddeliverycarecomplica+ons,expenditures

Sample:Allwomenwhohadpregnancyoutcomein2004-2005 Responserate84%

Seng: Korogocho:Olderandmorestablese>lement,12kmfromcitycenter,

higherpopula+ondensity,nearamunicipalwastesite,hashigherinfantandunder-5mortalityratethanViwandani

Viwandani:Se>lementneartheindustrialarea,7kmfromcenter Thisanalysis:Inclusioncriteria:womenwhodeliveredinhealthfacili;esinordertostudywomensexperiencewithfacility-basedbirth(n=1,266outof1,926) excluded81womenfounddeliveredinsengledbytradi+onalbirth

a>endant(TBA)

6


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9items-Informedbyqualita+veliteraturereviewandbyadvisorsinBal+moreandNairobi

Posi;veaspects Womanreceivedadequateprivacyduringexamina+on;

providerexplainedhealthstatus;

providerlistenedtoherques+onsorconcerns;

providerofferedcompassionatecare;

genuineinterestinherwellbeing.

Nega;veaspects leMaloneforlongperiods

of+me scoldedorshoutedatin

labor

Wastoldanoffensivecomment(insult)relatedtosexualbehavior

slappedinlabor.

Outcomes:deliverycareexperience

(1)


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(2)

ResponseScales Likert-typeresponsescaleofStronglyAgree,Agree,Disagree,orStronglyDisagree.

Unsurewasrecodedasthemiddlevalue,0. Itemswererecodedfrom-2to2;higherscore=be-erquality. Nega;velywordeditemswerereverse-coded.

Disagree=higherquality Fordescrip+veanalysis:dichotomizedresponses


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Step1.principalcomponentsanalysis(PCA)inourdata,PCAsuggested2components

Step2:exploratoryfactoranalysis(EFA)restrictedto2factors Wantloadingstobe.40anduniquenessvaluestobe


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QualityItem

Loading

Loading Unique

nessDeliveryCare(n=1263) Inthefacility,

providers Empathy Counseling Explainedyourhealth

statuswithtermsthatwereunderstandable. -0.63 0.81 0.39Listenedtoyour

ques+onsorconcerns. 0.20 0.40 0.71

Offeredcompassionate

care.0.79 -0.05 0.41

Showedagenuine

interestinyourwell

being. 0.60 0.12 0.53Scoldedorshoutedat

you.(Reversed(not) 0.64 -0.05 0.61

Empathyoutcomewas

standardized:meanof

0,SD~1(0.87),

range(-3.22to1.26).

Cronbachswas.56


(4)


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Mul+variateAnalysis

Dependentvariabledeliverycareempathy Independentvariables:

A)characteris+csofwomen B)u+liza+onofANCanddeliverycare Variablessignificantlyassociatedwithdeliverycare

empathyatbivariatelevel(ttest)wereenteredtoa

mul+variatemodel

ul;variatelinearregressionadjustedforclusteringbyenumera+onarea

(neighborhood)

checkedforcollinearity(vif)


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Results


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Wheredidwomendeliver?

41%

3%

20%

1%

24%

10%

Privateinse-tlements

(n=793)MissionHospital(n=51)

Gov'thospital(n=394)

Gov'thealthcenter

(n=28)Athome(n=467)

TBAhome/facility

(n=193)


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SampleCharacteris+csWomenwhodeliveredinHealthFacility(n=1266)

WomensCharacteris;cs

Age:64%age20-29,10%adolescents Educa;on:64%hadprimary,8%hadnone arried/inunion:83% Parity/Life;menumberofbirths:58%had2-4births;17%had

5

Occupa;on:Housework62%;21%trading/sellingServiceRelated ANCNumberofVisits:overhalfhadhad4ANC,1%none Deliverycareprovider:49%nurse/midwife,51%doctor/clinical

officer


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FrequencyofDeliveryCareExperiences(1)

83%

86%

72%

79%

83%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

privacyduringexam

explainedhealthstatus

listenedtoQsorconcerns

offeredcompassionatecare

showedgenuineinterest

Posi;veAspects(n=1263)

%Disagree

%Agree

Provider...

14%to28%Disagreed


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FrequencyofDeliveryCareExperiences(2)

8%

9%

14%

26%

0%10%20%30%40%50%60%70%80%90%100%

providersslappedyouinlabor

providersmadeoffensive

comments

providersscoldedorshoutedat

you

leMaloneforlongperiods

Nega;veAspects(n=1263)

%Disagree

%Agree

8%to26%agreed


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DeliveryCareExperiencesbyFacilityType

plementswererated

higherthangovt

hospitals(p


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IndependentVariables ul;variateodel(n=1263)

CoefficentStandard

Errorpvalue

Age:2029vs.lements

(r)0.09 0.10 0.395

GovernmentHospital -0.50 0.07 0.000

-


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ExploredEffectModifier:ExperienceofComplica+ons

Complica;on N%offacilitydeliveries

(n=1266)

Lastcomplica+onwasinpregnancy,severe 167 13%

Lastcomplica+onwasindelivery,severe 126 10%

C-sec+on 71 6%

Bloodtransfusion 25 2%

Suc+on 11 1%

Severecomplica+oninpregnancyordelivery,orC-sec+on,blood,orsuc+on

359 28%

StraLfymodelsbycomplicaLonsstatus


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IndependentVariables

Stra;fiedul;variateodels

NoComplica;ons(n=904) Complica;ons(n=359)

Coef (SE) p Coef (SE) p

Age:2029vs.lements(r)0.04 0.11 0.701 0.22 0.17 0.203

GovernmentHospital 0.55 0.08 0.000 0.35 0.11 0.003

GovernmentHealthCenter -0.03 0.16 0.852 -0.20 0.40 0.617Constant -0.04 0.21 0.835


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SummaryKeyMessages

21%ofwomendidnotreceivecompassionatedeliverycare;28%werelealonethisvariedsignificantlybyfacilitytype

14%to28%ofwomeninNairobiurbanse>lementsdisagreedwithposi+veaspectsofdeliverycare;8%to26%agreedwithnega+ve

InmulLvariatemodels,holdingotherfactorsconstants

Higherdeliverycareempathywasreportedbywomenwith: highesthouseholdwealth&occupa+onofselling/trading-among

motherswhodidnothavecomplica+ons

highestparity--amongwomenwithcomplica+ons. whoreportedadoctorvs.nurse/midwifeasskilledbirtha>endant

Lowerempathywasfoundamongallwomen: deliveringingovernmenthospitalsvs.privateinse>lementsand inmoredisadvantagedinformalse-lement(Korogocho)


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Seekclientsperspec;veandra+ngs Improvedeliverycareexperiencewithstandards-

basedqualityassurance

Iden+fywomenwhoreceivehigherandlowerqualityexperienceindeliverycareclosethegap

ResearchHouseholdsurveyscomplementotherdatasourcesQualita;veresearchcaninformdevelopmentand

explana+onofsurveyfindings

Validatedtoolwithmanyitemsisneeded,adaptedtolocalcontext

Implica+ons


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Idea:Rapidpost-deliveryappraisal

othersreportorrespondtoshortsurveyonmobilephones

ExampleofmTRACinUganda

ThroughthetollfreemTrac

SMSHotline,community

memberscanreporthealth

service-relatedissuesaerthe

service,includingstockoutsofessen+almalariadrugsin

hospitals.


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StudyLimita+onsandStrengths

Limita;ons

Cross-sec+onalsurveyin2006

Shortmoduleofques+onsondeliverycareexperience Experiencewithfacility-

basedbirth

PossibleRecallbias

Strengths

Largesamplesize-partofAPHRCMaternalHealth

popula+on-basedsurvey Householdsurveymay

overcomecourtesybiasin

exitinterviews

Informedbyliteraturereviewofqualityin

maternalhealth&experts

atJHSPH&inKenya


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Acknowledgements Jhpiego:supporttoGMHC2013 Reviewers:D.Becker,V.Tripathi,B.Dao JHSPH:Disserta+onAdvisor:M.Koenig,&

Commi>ee:J.Bertrand,A.Tsui,D.Peters,V.Go Popula+on,FamilyandReproduc+veHealthDepartment:

Academicguidance,grantstostudent

APHRC:hosteddoctoralstudentintern,adviceofJCFotso25

Asanteni

Thankyou


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SupplementalSlides


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LiteratureReviewedonDeliveryCareExperience

priortostar+ngstudy

EasternAfrica:PearsonandShoo2005 Ghana:D'Ambruoso,AbbeyandHussein2005;Millsand

Bertrand2005

Kenya:Mooreetal.2002 Morocco:Belghi+etal.1998 Niger:Jaffre,Prual1994 Nigeria:Osubor,FatusiandChiwuzie2006,

S.Africa:Jewkes,AbrahamsandMvo1998 Tanzania:Gilson,Alilio1994 Uganda:Amoo+-KagunaandNuwaha2000;Weeksetal.

2005

La+nAmerica:Camperoetal.1998;Milleretal.2003


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OverviewofMethodstoStudy

Client-ProviderInterac+ons

Client Perspectives Household Survey

Exit (at clinic) Clinic attendees

outside of clinic

Samples fromsurveillance database

at household

Focus Groups

Sorting Exercises / ConceptMapping

Ethnographic

28

u Provider Perspectives Surveys Interviews FGDs Review of hypothetical

cases

Role-playing with coachedclients

Source: Bazant 2007, Adapted from Simmons and Elias, 1994

u Observations Using checklists or

structured guides

Audio or videotapes Simulated client

women's ratings of the experience of delivery care: household survey from nairobi's informal...

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