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While disrespectful treatment of pregnant women attending health care facilities occurs globally, it is more prevalent in low-resource countries. In Kenya, a large body of research studied disrespectful maternity care (DMC) from the perspective of the service users. This paper examines the perspective of health care workers (HCWs) on factors that influence DMC experienced by pregnant women at health care facilities in rural Kisii and Kilifi counties in Kenya. We conducted 24 in-depth interviews with health care workers (HCWs) in these two sites. Data were analyzed deductively and inductively using NVIVO 12. Findings from HCWs reflective narratives identified four areas connected to the delivery of disrespectful care, including poor infrastructure, understaffing, service users’ sociocultural beliefs, and health care workers’ attitudes toward marginalized women. Investments are needed to address health system influences on DMC, including poor health infrastructure and understaffing. Additionally, it is important to reduce cultural barriers through training on HCWs’ interpersonal communication skills. Further, strategies are needed to affect positive behavior changes among HCWs directed at addressing the stigma and discrimination of pregnant women due to socioeconomic standing. To develop evidence-informed strategies to address DMC, a holistic understanding of the factors associated with pregnant women’s poor experiences of facility-based maternity care is needed. This may best be achieved through an intersectional approach to address DMC by identifying systemic, cultural, and socioeconomic inequities, as well as the structural and policy features that contribute and determine peoples’ behaviors and choices.
A descriptive qualitative study involving in-depth interviews with 24 HCWs was conducted. Interviews took place between January and March 2020 in rural Kilifi and Kisii counties, where the Aga Khan University has been implementing a Maternal Newborn and Child Health (MNCH) project since 2015. Kilifi and Kisii are two of the poorest counties in Kenya, with high maternal mortality and morbidity rates. In Kenya, the proportion of women delivering at health facilities is 61%, while, in Kilifi and Kisii, this stands at 52.6% and 69%, respectively [22]. The poor treatment of women by HCWs during pregnancy and delivery in part contributes to these relatively low figures [13,18]. Many women continue to deliver at home with the help of traditional birth attendants (TBAs). Further, the rate of teenage pregnancies in both counties remains higher than the national average [22]. A total of 24 HCWs (18 females and 6 males), 12 in each site, who worked for at least one year in Access to Quality Care for Extending and Strengthening Health Services (AQCESS) target facilities, were purposively sampled by AQCESS project implementation project managers knowledgeable with Kisii and Kilifi. We exclusively targeted HCWs, because AQCESS previously conducted a gender assessment study with service users that provided insights on their experience of DMC [1] and developed a strong rapport with the facility staff. Qualitative in-depth interviews of 24 HCWs across the two study sites were conducted. Ethical approval for this study was obtained from the Aga Khan University, East Africa and National Commission for Science Technology and Innovation research permit NACOSTI/p/19/2768 on 3 December 2019. Interviews were held within the facilities at a time convenient to the HCWs. Interviewers were trained by the study Principal Investigator (PI) and familiarized themselves with the interviewer guide (Appendix A). Study interviewers explained the purpose of the study to the participants who were voluntarily asked to consent (Appendix B). The interviewer guide (Appendix A) was used to direct the interview process, and all interviews were audio recorded. After the interview, a debrief statement (Appendix C) was read to each participant who were then given an opportunity to ask questions. Data from audio recorders was transcribed verbatim by a qualified transcribing company. Identifiers, such as names, were removed, and all data were transferred to the Monitoring and Evaluation and Research Learning (MERL) unit at the Centre for Excellence in Women and Child Health at Aga Khan University. Transcripts were randomly selected by AL, who read and developed the initial code book using a qualitative data analysis software (NVIVO 12— QSR International (1999) NVivo Qualitative Data Analysis Software [Software]. Available from https://qsrinternational.com/nvivo/nvivo-products/). The code book was used by the Research Assistants (RAs) to code all the remaining transcripts. AL reviewed the coded data and merged the main and sub themes. SW read all the codes and developed the final code book.
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