Promoting respectful maternity care: challenges and prospects from the perspectives of midwives at a tertiary health facility in Ghana

listen audio

Study Justification:
The study aimed to explore and document midwives’ perspectives on the challenges and prospects for promoting respectful maternity care (RMC) in a tertiary health facility in Ghana. This research was justified by the evidence showing that women in Ghana often experience disrespectful care during childbirth, and there is a need for evidence-based research to advance the adoption of RMC by midwives.
Highlights:
1. The study identified three main themes related to RMC: emotional support, dignified care, and respectful communication. These themes align with the World Health Organization’s quality of care framework.
2. Current actions promoting RMC included providing sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit.
3. Challenges to providing RMC included logistical constraints for privacy and free movement of clients, alternative birthing positions, poor attitudes from some midwives, workload, and language barriers.
4. Recommendations to improve RMC promotion included appointing more midwives, providing logistics for alternative birthing positions and privacy, and implementing continuous training and capacity building.
Recommendations for Lay Reader and Policy Maker:
1. Lay Reader: The study highlights the importance of respectful maternity care and the challenges faced by midwives in providing it. The recommendations emphasize the need for more midwives, improved logistics, and continuous training to promote RMC. Lay readers can use this information to advocate for better maternity care and support initiatives that prioritize respectful and dignified treatment during childbirth.
2. Policy Maker: The study provides valuable insights into the challenges and prospects for promoting RMC in a tertiary health facility in Ghana. The recommendations suggest practical steps such as increasing the number of midwives, providing necessary resources, and implementing training programs. Policy makers can use this information to inform policy decisions, allocate resources, and develop strategies to improve maternity care services and ensure respectful treatment for women during childbirth.
Key Role Players:
1. Midwives and Nurses: They play a crucial role in providing respectful maternity care and implementing the recommendations.
2. Social Scientists: They contribute to the research design, data analysis, and interpretation of findings.
3. Surgeon: Their expertise can provide insights into the medical aspects of respectful maternity care.
4. Bio-statistician: They contribute to data analysis and ensure the accuracy and reliability of the study findings.
Cost Items for Planning Recommendations:
1. Recruitment and Training of Midwives: Budget for recruiting and training additional midwives to address the shortage and improve the quality of care.
2. Logistics and Resources: Allocate funds for providing necessary resources such as equipment, supplies, and infrastructure to support alternative birthing positions and ensure privacy.
3. Continuous Training and Capacity Building: Budget for organizing training programs and workshops to enhance midwives’ skills and knowledge in providing respectful maternity care.
4. Research and Evaluation: Allocate funds for future research and evaluation to monitor the progress and effectiveness of the implemented recommendations.
5. Monitoring and Supervision: Budget for regular monitoring and supervision to ensure adherence to RMC practices and identify areas for improvement.
Note: The provided cost items are for planning purposes and do not reflect the actual cost.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a qualitative study design, which allows for in-depth exploration of midwives’ perspectives on promoting respectful maternity care. The study employed rigorous data collection and analysis methods, including interviews with trained midwives, verbatim transcription of audio data, and the use of NVivo-12 for data management and analysis. The findings were categorized into three themes that align with the WHO’s quality of care framework. The abstract also mentions the current actions, challenges, and recommendations identified by the midwives. However, to improve the strength of the evidence, the abstract could provide more specific details about the sample size, inclusion criteria, and the process of ensuring data integrity and validity. Additionally, it would be helpful to include information about the limitations of the study and any potential biases that may have influenced the findings.

Background: Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives’ perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility. Methods: We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study. Results: The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO’s quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building. Conclusion: We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities.

The research team consisted of midwives and nurses (VMD, ABBM, JRL), social scientists (JO), a surgeon (PD) and bio-statistician (PA, EKN). As such, they had no influence over the study participants and overall data collection dynamics. Moreover, interviewers who could speak both Twi and English language and had vast experience in qualitative research interviewing were recruited to support the data collection process. The research assistants were taken through intensive training for three days in order to deal with any conscious and sub-conscious biases that could have compromised the integrity of the study. The interviewers had no direct influence on the study site, methodological procedures, and findings of the study. As a result of this reflexivity exercise, all of the study authors were able to collaborate more effectively since they were able to grasp each other’s perspectives, which added to the study’s rigour. The study adopted an exploratory descriptive qualitative approach. This design allowed us to explore midwives’ perspectives concerning challenges faced and prospects available for promoting RMC by gathering in-depth information through face-to-face interviews. Qualitative exploratory design served as the most appropriate design for this study since we were concerned about gaining broader and deeper insight about the phenomenon under study. Moreover, we adopted this study design because it allows us the flexibility to respond to varied research questions including questions that border on what, why and how the phenomenon under study happens [16]. Purposive sampling technique was used to sample the participants who met the inclusion criteria. The inclusion criteria included the following: (a) participant should have participated in the RMC training, and (b) they should be providing maternity services and willing to participate in the study. In the year preceding the study, midwives at the study site undertook training on RMC. We trained 110 midwives on four separate training period. The training modules taught the trainees how to use effective, alternative birthing positions, focused antenatal care, empathetic and ethical communication with childbearing women, and demonstrating respect and dignity during intrapartum care provision to promote quality intrapartum care free of violence and abuse. Six months after the training, the research team visited the Obstetrics and Gynecology department of the hospital to discuss the study in detail. Two ward-in-charges volunteered as the study’s ‘recruitment links’ Trained research assistants (RAs) visited the hospital to meet with trained midwives through the ward-in-charge as the recruitment link. The study objective was explained to the participants who were eligible, and they were given a copy of the research’s information sheet. We granted prospective participants two-week window to read and review the information sheet in order to guide their decision to either participate or not participate in the study. Midwives with informed decision of participation contacted the RAs via phone for further arrangements on date, time and venue of the interview. Inform consent by writing (n = 11) and thumb printing (n = 1) were obtained prior to the interviews. It was only after the signed informed consent form had been received that our RAs proceeded to start the interviews. The study was conducted in the maternity block of a tertiary hospital within the Kumasi Metropolis in the Ashanti region of Ghana. This facility is recognised as Ghana’s second largest hospital and the only tertiary hospital in the Ashanti region [17]. It provides healthcare to patients across the country but particularly serves the middle and savannah zones of Ghana. As such, it serves as the primary referral hospital for the Ashanti, Bono, Bono-East, Ahafo, Savannah, Northern and North-East regions as well as some neighbouring countries. The facility has a bed capacity of about 1200 and staff strength of about 3000. It has thirteen (13) clinical directorates (departments) one of which is the Obstetrics and Gynaecology (O &G) directorate, which has four labour wards. In 2018, the hospital recorded an estimated 4792 Spontaneous vaginal deliveries, an estimated 123 maternal deaths, and 61 neonatal deaths [14]. The midwife staff strength at KATH is 381. Table 1 provides statistics on the care provided between 2019 and 2021. Statistics on care provided between 2019 and 2021 ABBM, a qualitative researcher with clinical and academic experience in women’s health and maternal care worked collaboratively with three research assistants (RAs) who had undergone a two-days training about the objectives and procedures for data collection for this study, to conduct the face-to-face interviews with midwives. The interviews were conducted using semi-structured interview guide which was developed based on the WHO’s quality of care framework and an RMC module (RMC-M) developed by the first author in her preliminary studies. For each midwife, we approached them and discussed the objectives and procedures for the study. Additionally, their rights as participants were clearly stated to them as well as any possible discomfort, benefits and compensations. After all these have been explained to the midwife, their consent to voluntarily participate was obtained. All interviews were conducted were conducted as a one-off interview, and at a date, time and place of convenience to participants. The researcher and RAs asked probing questions in order to elicit rich qualitative data for analysis. Data collection began on May 1 through to August 9, 2021. On average, interviews lasted about 70 minutes. All interviews were audio recorded after seeking consent from the participants. In addition to the audio recording, the RAs captured other non-verbal cues and gestures through note taking and observation. By the 10th interview, we had reached saturation as no new analytical information was emerging from the interviews. We conducted additional two interviews to confirm that indeed we had gotten to the point of data saturation. We did not encounter any situation where participants refused to participate in the study. Also, none of the participants dropped out at any point in the study. Ethical approval was obtained from the Committee on Human Research, Publication, and Ethics (CHRPE) at the Kwame Nkrumah University of Science and Technology (KNUST) (reference number: CHRPE/AP/181/18) and the Komfo Anokye Teaching Hospital (KATH) Institutional Review Board (reference number: RD/CR17/289). We anonymised information by giving pseudonyms to the participants in order to protect their identities and prevent third parties from tracing data back to participants. Written informed consent was sought from participants in order for them to voluntarily participate in the study after having read and understood the terms, risks and benefits associated with their participation. Also, the recorded interviews were encrypted to prevent third parties from having access to it. Interview venue (Office at KATH), date and time were determined by the participants. Interview language was Twi (local language). Both the interviewer and researchers could speak and understand Twi on a full professional competence level. The audio files from the interviews were transcribed verbatim. ABBM proofread the transcribed interviews alongside listening to the audio files as a way of ensuring that, the transcripts reflected exactly what the participants stated. Two independent translators fluent in both the Twi and English languages then translated the twelve anonymised “Twi” transcripts using the process of back-back translation while maintaining confidentiality. Independent thematic coding analysis using QSR NVivo-12 was performed by two data analysts (PA and JO). Translated transcripts were imported into NVivo-12 for data management and analysis. Codes were generated through inductive analysis to create themes and sub-themes. This inductive analysis was done by reading the raw text data and discussing the emerging issues to form themes. Significant recurrent statements or phrases were retrieved as codes from participants’ transcripts to provide data that directly relate to the issue under research. The relevant statements or phrases were then used to develop formulated ‘meanings’ that described and illuminated the obstacles and opportunities for promoting RMC. Following that, themes were created based on various statements with comparable meanings. This process was repeated for all the 12 transcripts. Insights from the transcripts were broadly presented in line with the main questions in the semi-structured guide. To completely develop the ideas, the original themes were followed in subsequent interviews and validated using field notes. The initial analysis was performed by PA and JO, and later validated by the first, second, and third authors and through member checking with five participants. These participants reviewed the printed transcript so as to confirm the accuracy in the presentation of their views. Member checking allowed us to confirm the findings from our analysis. However, none of the issues changed after member checking. Recognising the worth of rigour and trustworthiness in qualitative research, we ensured that our study and its methods adhered strictly to the principles of credibility, confirmability, transferability, and authenticity. Transferability was ensured by giving detailed description of the study objectives, research design, data collection procedures, study contexts and data analysis procedures. Confirmability was ensured by allowing five of the participants to review the printed transcript so as to confirm the accuracy in the presentation of their views. To authenticate the results, completed interviews were first reviewed by the interviewers. After that level of review, VMD, who is project lead and an experienced qualitative researcher together with ABBM and EKN validated the results. To ensure credibility, we adhered strictly to the study protocol and ensured that audio data were transcribed verbatim.

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Training and Capacity Building: Implement continuous training programs and capacity building initiatives for midwives to enhance their knowledge and skills in providing respectful maternity care (RMC). This can include training on effective communication, alternative birthing positions, focused antenatal care, and demonstrating respect and dignity during intrapartum care provision.

2. Increased Staffing: Address the challenge of workload by appointing more midwives to ensure adequate staffing levels. This can help reduce the burden on individual midwives and improve the quality of care provided to pregnant women.

3. Logistics Support: Provide necessary logistics and resources to support alternative birthing positions and ensure privacy during childbirth. This can include providing appropriate birthing equipment, such as birthing stools or mats, and creating private spaces for women to give birth.

4. Language Support: Address the language barrier challenge by ensuring that midwives have access to language interpretation services or are proficient in the local languages spoken by pregnant women. This can help improve communication and understanding between midwives and pregnant women.

5. Promote Emotional Support: Continue promoting emotional support for pregnant women through actions such as providing sacral massages and reassurance. This can help create a supportive and comforting environment during childbirth.

6. Strengthening Referral Systems: Enhance referral systems to ensure that pregnant women who cannot afford maternity care are referred to the appropriate social welfare units for financial support. This can help improve access to maternal health services for vulnerable populations.

It is important to note that these recommendations are based on the specific challenges and perspectives highlighted in the provided research study. Implementing these innovations would require collaboration between government agencies, hospital administrations, and healthcare providers to address the identified challenges and improve access to respectful maternity care.
AI Innovations Description
Based on the provided description, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Increase the number of midwives: The midwives in the study recommended the appointment of more midwives to address the challenges in providing respectful maternity care (RMC). This recommendation can be developed into an innovation by implementing strategies to recruit and train more midwives, ensuring an adequate workforce to meet the demand for maternal health services.

2. Provide logistics support: The midwives also recommended the provision of logistics to support alternative birthing positions and privacy. This can be developed into an innovation by equipping healthcare facilities with the necessary resources and equipment to facilitate different birthing positions and ensure privacy during childbirth.

3. Continuous training and capacity building: The midwives suggested the implementation of continuous training and capacity building to promote RMC. This recommendation can be developed into an innovation by establishing comprehensive training programs that focus on RMC practices, communication skills, and respectful care. This can help improve the knowledge and skills of midwives in providing quality maternal health services.

4. Address poor attitudes and language barriers: The study identified poor attitudes from some midwives and language barriers as challenges to providing RMC. To address these issues, an innovation could involve implementing strategies to improve midwives’ attitudes and communication skills, as well as providing language support services to ensure effective communication with diverse populations.

5. Improve logistical constraints: The study highlighted logistical constraints for ensuring privacy and free movement of clients as challenges to providing RMC. An innovation could involve developing solutions to address these constraints, such as redesigning healthcare facilities to provide private and comfortable spaces for childbirth, and implementing systems to streamline the movement of clients within the facility.

By implementing these recommendations as innovations, access to maternal health can be improved by promoting respectful maternity care and addressing the challenges identified in the study.
AI Innovations Methodology
Based on the provided description, the research study focuses on exploring midwives’ perspectives on challenges and prospects for promoting respectful maternity care (RMC) in a tertiary health facility in Ghana. The study employed an exploratory descriptive qualitative approach, conducting 12 interviews with midwives educated on RMC. The findings were categorized into three themes: emotional support, dignified care, and respectful communication, which align with the WHO’s quality of care framework. The study identified current actions that promote RMC, challenges faced, and recommendations to improve RMC promotion.

To improve access to maternal health, here are some potential recommendations based on the study’s findings:

1. Increase the number of midwives: The midwives recommended the appointment of more midwives to address the workload and ensure adequate care for pregnant women.

2. Provide logistics for alternative birthing positions and privacy: The study identified logistical constraints for ensuring privacy and free movement of clients, as well as the need for support in implementing alternative birthing positions. Providing the necessary equipment and resources can improve access to different birthing options and enhance women’s experience during childbirth.

3. Continuous training and capacity building: The midwives recommended the implementation of continuous training programs to enhance their skills and knowledge in providing respectful maternity care. Ongoing training can help address any gaps in knowledge and ensure that midwives are up-to-date with best practices.

Methodology to simulate the impact of these recommendations on improving access to maternal health:

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Define the indicators: Identify specific indicators that reflect improved access to maternal health, such as the number of women receiving respectful maternity care, reduction in maternal mortality rates, increased satisfaction among pregnant women, or improved health outcomes for mothers and newborns.

2. Collect baseline data: Gather data on the current state of access to maternal health, including the number of midwives, availability of resources for alternative birthing positions, and existing training programs. This data will serve as a baseline for comparison.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on access to maternal health. The model should consider factors such as the number of additional midwives, the availability of logistics for alternative birthing positions, and the implementation of continuous training programs.

4. Input data and run simulations: Input the baseline data into the simulation model and run simulations to estimate the potential impact of the recommendations. The model should consider different scenarios, such as varying the number of additional midwives or the level of resources provided for alternative birthing positions.

5. Analyze results: Analyze the simulation results to assess the projected impact of the recommendations on improving access to maternal health. Evaluate the changes in the identified indicators and compare them to the baseline data.

6. Refine and validate the model: Refine the simulation model based on feedback and validation from experts in the field of maternal health. Ensure that the model accurately reflects the potential impact of the recommendations.

7. Communicate findings: Present the simulation findings in a clear and concise manner, highlighting the potential benefits of implementing the recommendations. Use the findings to advocate for policy changes or resource allocation that can improve access to maternal health.

By following this methodology, stakeholders can gain insights into the potential impact of the identified recommendations on improving access to maternal health. This information can guide decision-making and resource allocation to prioritize interventions that have the greatest potential for positive change.

Yabelana ngalokhu:
Facebook
Twitter
LinkedIn
WhatsApp
Email