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Table 4 Characteristics of included studies

From: Effectiveness of respectful care policies for women using routine intrapartum services: a systematic review



Abuya 2015, Kenya

Multicentre pre-post design

Participants: Inclusion criteria at both time points: (Postbirth interviews: All women aged 15–45 who had given birth in the previous 24–48 h in the 13 Kenyan facilities taking part in the Heshima project, between Sept 2011 and Jan 2012 (baseline) and Jan and Feb 2014 (endline): Labour observations: All women aged 15–45 in labour in the included facilities/timepoints who gave consent to observation during early labour.

Interviews: N = 641 (baseline: ‘50% of all births in the previous 48 h’) and 728 (endline: 60% of all births in the previous 48 h)

Labour observations: N = 677 (baseline) and 523 (endline). It isn’t clear if some of these are the same women as those who completed surveys, or what % of those eligible agreed to take part.

Intervention: Multi-component multi-system change programme designed to train maternity care providers in respectful care, as well as to reduce D&A:

• Training in values and attitudes transformation

• Set up of quality improvement teams

• Caring for carers

• D&A monitoring

• Mentorship

• Maternity open days

• Community workshops

• Mediation/alternative dispute resolution

• Counseling community members who have experienced D&A

Control group: (pre-intervention): Usual care (not described)

Risk of bias assessment: lack of allocation concealment, lack of blinding, and the possible impact of interventions other than those specified in the intervention

Ratcliffe et al. 2016 (a, b) Tanzania

Single centre pre-post design

Participants: Baseline (April-Oct 2013) For observations, ‘women presenting at the registration desk were systematically sampled’. For women’s views, every second woman on the postnatal ward at about 3–6 h postnatal systematically sampled for inclusion. 200 direct observations from admission to 2 h postpartum (paper a; reported as 208 in paper b). N = 2000 interviews on the postnatal ward (paper a; reported as 1914 in paper b). Subsample of 77 women re-interviewed in their homes 4–6 weeks postnatal (of the 100 who were both observed and interviewed on the postnatal ward (paper a), reported as 70 in some analyses in paper a, and as 64 in paper b. Structured interviews with all 50 local maternity providers and administrators; 18 also did in-depth interviews. Post-intervention: ‘Every second woman registering at the facility for delivery was selected for observation’. ‘Women who had attended an Open BirthDay (OBD) session were selected for observation’. Total observations = 459. Structured community interviews 4–6 weeks postpartum, based on ‘systematic’ selection from the OBD register and those directly observed (n = 149). All providers and administrators were interviewed (55/76, 72%).

Intervention: a three-part step-wise dissemination and participatory process with local stakeholders from the facility, district community, and national representatives, and a multi-stakeholder working group. Two components were developed. The first (May-Oct 2014) was a series of Open Birth Days (antenatal education, communication, and information sessions for women re birth and what would happen to them in hospital, their rights, what they should bring in, open discussions between attendees and staff to build trust, tours of the hospital, including the complaints department; accompanied by posters of the ‘universal rights of childbearing women’, translated into Kiswahili and hung on all the wards, notebook copies sent to all staff, and postcard copies given to all women attending the sessions). All 362 eligible women during the intervention phase attended an OBD session. The second was a Respectful Care Workshop, held over 6 sessions over 2 days between April and May 2014, and ending with an agreed action plan agreed by each participating group, based on the WHO Health Workers for Change curriculum. 76/88 eligible staff took part, in groups of 15–20, including senior staff and administrators (in a separate group to frontline staff).

Control: pre-intervention (usual care, not described)

Risk of bias assessment: lack of allocation concealment, lack of blinding, and the possible impact of interventions other than those specified in the intervention

Kujawski et al. 2017, Tanzania

Cluster randomized study (two sites, multiple facilities in each site, approx. 60 km apart)

Participants: (surveys at baseline: Dec 2011 to May 2012; and at endpoint; March to Sept 2015) Postpartum women aged 15 or over were asked to consent to take part as they left the facility. N at baseline = 1388/2085 (66.6%); n at endpoint = 1680/2324 (72.3%).

Intervention (one site): 1) Participatory process with multiple community and facility stakeholders, designed to create a Client Service Charter built on consensus on norms to foster mutual respect and respectful care. The Charter was then widely disseminated in communities and local health facilities (6 months). 2) Quality Improvement process in one local facility to address D&A as a system-level issue. This comprised plan-do-act type cycles with local staff, resulting in a number of local changes such as provision of curtains to ensure privacy, transparency about stock-outs, running continuous customer satisfaction exit surveys, providing tea for on-shift staff, best-practice sharing with other wards and the regional hospital, counselling staff who showed D&A behaviours, and mutual encouragement amongst staff to exhibit respectful care (11 months managed by the research team, then 10 months without the research team, prior to formal evaluation).

Control group: usual care (not described). Authors note some observed changes over time in the control site, including posting of patients’ rights in the maternity ward, a pharmacy price list, and renovations that increased service user privacy.

Risk of bias assessment: Lack of allocation concealment, self-report outcome measures only, only one site in each arm

Umbeli et al. 2014 Sudan

Single-centre pre-post design, using structured questionnaires

Participants: Baseline: All local health care providers (120); 10% sample of women giving birth in the hospital before the training (2000). Post-intervention: All local health care providers (105); 10% sample of women giving birth in the hospital after the training (2469).

Intervention: Training of registrars, house officers, midwives and data collectors on communication skills, support during childbirth, providing information, and empathy.

Control: pre-intervention (usual care, not described)

Risk of bias assessment: Observational study, lack of allocation concealment, self-report outcome measures only

Brown et al. 2007, South Africa

Pilot cluster RCT (10 hospitals, randomized 5:5)

Participants: sites were selected if they had more than 80 births/month from a list of maternity sites within a 200 km radius of Johannesburg. They included community, district, and referral units. Those linked to university academic departments were excluded. Baseline: 2090 postnatal women were interviewed from Oct 2008 (excluding those with elective CS). 2058 postnatal were interviewed in December 2009, 8 months after the intervention was introduced.

Intervention; an educational intervention to promote childbirth companions to improve clinical outcomes and quality of care and promote a more woman-friendly service. Introduced to the 5 randomised sites in the two months subsequent to the introduction of the WHO RHL facilities (see below). It included an interactive workbook for use in a workshop, and the workshop itself; posters and banners encouraging women to bring in a companion; illustrated pamphlets for staff and pregnant women to show how companionship could be promoted locally; a magazine style video on birth companionship including interviews with recent South African mothers and with staff. Encouragement by the research team for senior staff to attend the workshop. The research team ran the workshop. Visits by the research team every two weeks to discuss progress, and how to overcome obstacles.

Control group: usual care plus: All 10 sites were given access to the WHO Reproductive Health Library, computer hardware, and training to promote evidence based information (over two months in 1999). The 5 control hospitals were also given an evidence based intervention to promote external cephalic version, including a lecture, group discussion, a video demonstration, and an invitation to attend training in ECV

Risk of bias assessment: Lack of allocation concealment, self-report outcome measures only

  1. Abbreviations: D&A – disrespect and abuse; RCT – randomized controlled trial; CS – caesarean section