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Background: Despite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care. Methods: We used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages. Results: The implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima’s successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care. Conclusion: We found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to understanding a range of interventions that can begin to address issues of mistreatment in maternity care; replication of these activities is needed globally to better understand if the Heshima implementation process can be successful in different countries and regions.
Heshima is an evidence-based participatory implementation research study conducted in 13 facilities in five Central and Western Kenya counties that began in 2011. It engaged a range of community, facility, and policy stakeholders to address the causes of disrespect and abuse during childbirth and promote RMC [18]. The Heshima consortium was led by Population Council (hereafter known as The Council), an international research organization with an extended history (since 1960s) of operations research and support for policy and program development in Kenya with particular focus on quality of reproductive (and maternal) healthcare. The Council collaborated with FIDA, co-authors of Failure to Deliver 2007, which highlights issues of mistreatment, and advocates for women’s rights at local and national levels [7]. Heshima’s other key member was the National Nurses Association of Kenya/Midwifery Chapter (hereafter known as the Nurse/Midwife Association), a member of both the International Council of Nurses and International Confederation of Midwives, who empower their members (nurses and midwives) to provide quality care. The project steering committee included representatives of two departments within the Ministry of Health (MoH), the Division of Reproductive Health and the Department of Nursing; the Nursing Council of Kenya; and a core group of stakeholders interested in improving access to quality maternal and newborn health (MNH) care in a rights-based approach. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. A timeline (Fig. (Fig.1)1) depicts key events over the project period which guided research for this paper. Heshima timeline of data collection and critical external factors Continuous process documentation facilitated the triangulation of qualitative findings from focus group discussions, in-depth interviews, and dialogues with participants and beneficiaries. A detailed description of the methodology used for baseline and outcome data collection, is described elsewhere [18, 19, 24]. In brief, we conducted a before-and-after study designed to measure the effect of a package of interventions to reduce the prevalence of disrespect and abuse experienced by women during labor and delivery in 13 Kenyan health facilities. A range of empirical study tools were used (observations of client-provider interactions, client exit interviews, provider interviews, facility inventories). Prevalence data were collected through an exit survey of 641 women discharged from postnatal wards at baseline [13, 14], and compared with 728 at endline to assess the impact of the interventions. We also describe changes in observed behaviour at endline [18] (See project objectives in Table Table11). Heshima project objectives Qualitative baseline and endline data were collected in September and October 2011 and January and February 2014, respectively, with a range of intervention participants. Supplementary data were retrieved from various sources such as summary reports, project reports and additional interviews. Summary reports were used from two critical meetings held in early 2012, a ‘community dialogue meeting’ and ‘stakeholder forum’, that disseminated baseline data to stakeholders and solicited recommendations for the development of a package of Heshima interventions. Information from these meetings was compiled and recorded in internal project reports. The complementary process documentation throughout the project period facilitated the translation of evidence into actions resulting in the consistent monitoring of intervention processes, notation of contextual effects, and afforded opportunities for addressing inherent challenges to implementation. Additional focus group discussions and in-depth interviews were obtained from a selected facility and its surrounding community between April and August, 2013 (Table (Table22). Data sources and study participants over the course of the intervention Informed consent was obtained from all adult study participants. There were no minors included in the study. The research protocol was approved by the Division of Reproductive Health, Ministry of Health, as well as the Kenya Medical Research Institute (KEMRI)‘s Ethical Review Board (SCC 288) and the Council’s Institutional Review Board (Protocol 517). This paper uses the CFIR as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process integral for triangulating qualitative data (23). CFIR is an amalgamation of several frameworks developed to evaluate complex intervention processes in the real world. It builds on theories of dissemination, innovation, organizational change, knowledge translation, implementation, and evidence-based interventions [23]. CFIR emphasizes stakeholder perceptions as central to the evaluation of an intervention from the design phase to intermediate and final outcomes by using five specific domains: intervention characteristics, inner setting, outer setting, characteristics of individuals involved, and process of implementation [23]. Currently, CFIR’s use has been limited to disease-specific or targeted behavior change interventions [25, 26]. We applied the analytic framework in an iterative process to describe the complexity of Heshima’s policy, facility, and community activities. The range of perceptions in Heshima’s qualitative evaluation, allowed us to deductively apply a modified version of CFIR (using a number of the constructs within the five domains) to gain an understanding of Heshima’s implementation process, strengths, and challenges. Thematic analysis by internal researchers (i.e. those directly involved in the implementation research) and external researchers (those with contextual knowledge) revealed gaps in addressing factors or drivers of disrespect and abuse at baseline (e. g. lack of awareness of rights for childbearing women, providers ‘carrying stress’), changes perceived by women delivering in study facilities, external influences experienced afterwards, and reflections about the process and outcomes of Heshima at endline (e.g. what worked well, or not, characteristics of individuals, influences on implementation). Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. We generated categories of themes/issues for analysis found across the intervention design and implementation stages. Salient information extracted from process documentation (e.g. dates, coverage of activities, tools, outputs and outcomes) contextualized the implementation at the various intervention levels. Reflexive discussions of the data and broad issues faced during the implementation process included both internal (i.e. those directly involved in implementation) and external perspectives. This discursive, team-based methodology using CFIR corroborated multiple data sources, along thematically organized lines that fashioned inferences about Heshima’s implementation.
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