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Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Imagining maternity care as a complex adaptive system: understanding health system constraints to... RESEARCH ARTICLE Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care a b c d Anteneh Asefa , Barbara McPake , Ana Langer, Meghan A. Bohren , Alison Morgan a PhD Candidate, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Assistant Professor, School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia. Correspondence: antex98@yahoo.com b Professor, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia c Professor, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA d Senior Lecturer, Gender and Women’s Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Carlton, Australia e Associate Professor, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia Abstract: Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee- exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC. DOI: 10.1080/ 26410397.2020.1854153 Keywords: respectful maternity care, health system, complex adaptive system, system hardware, system software Introduction Africa. Key to achieving the sustainable develop- Despite the implementation of a range of ment goal target of reducing the global maternal maternal health interventions, maternal mortality mortality ratio to 70 per 100,000 live births by remains high in many low- and-middle-income 2030 is improving the quality of both clinical countries (LMICs), including those of sub-Saharan and non-clinical care women receive during the 456 © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduc- tion in any medium, provided the original work is properly cited. A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 time of pregnancy, childbirth, and in the immedi- Given the diverse contributors to the mistreat- 3 22 ate postpartum period. ment of women during childbirth, system com- The World Health Organization (WHO) defines plexity-informed strategies need to be designed the quality of care as “the extent to which health to advance context-specific and evidence-based care services provided to individuals and patient maternal health interventions. Although RMC, populations improve desired health outcomes” as a non-clinical aspect of quality care, relies on and outlines that safety, effectiveness, timeliness, the practice of service providers, it is open to efficiency, equity, and people-centredness of the interactions between other system com- health services are integral to achieving quality. ponents such as infrastructure, information and Applying this definition to maternal and newborn referral systems, financing, and motivation, 23,24 health services helps to view quality from two among others. standpoints: quality from the perspective of the Positioning RMC in a complex system helps to provision of care (clinical care) and quality from explore the constraints and patterns of interaction the perspective of how women and their families between system elements that directly or experienced the care (interpersonal care). Histori- indirectly affect the delivery of RMC in health cally, however, most quality improvement inter- facilities. In this study, the maternity care system ventions have focused on the clinical dimensions is regarded as a complex adaptive system. Accord- of maternity care while overlooking the interper- ingly, the concepts of complex adaptive systems sonal and social aspects of care. were used to guide data analysis and interpret- The mistreatment of women during facility- ation of the findings of this study. based childbirth has been reported as both a vio- The concepts of complexity science are rooted lation of women’s human rights and a significant in disciplines including biology, chemistry, phy- deterrent to the utilisation of skilled birth ser- sics, and sociology, among others. Consequently, 7–9 vices. Several studies from sub-Saharan Africa, several theories including evolutionary theory in including WHO-led studies, reported high biology, self-organisation theory in chemistry, 10,11 7,12 levels and diverse manifestations of the and chaos theory in mathematics contributed to mistreatment of women. Similarly, the worryingly the complexity science construct, the latter result- high level of mistreatment of women in Ethio- ing in a heightened interest in complexity science 13–16 pia highlights the need for a focused strategy among social scientists to study change, evolution, if the country is to improve maternal health and adaptive, and emergent behaviours in social and reduce maternal mortality. In 2019, only 47.5% organisational phenomena such as health- 27–29 of pregnant women gave birth in health facilities care. Complexity science resulted in the para- in Ethiopia although 74% of pregnant women digm shift from the linear cause and effect inquiry received at least one antenatal care visit from a underlying traditional formal approaches, to syn- skilled provider. A portion of this missed oppor- thetic reasoning and modelling of complex tunity may be addressed by preventing the mis- systems. 7,18 treatment of women. A complex adaptive system is a dynamic system Respectful maternity care (RMC) is one of the that consists of a wide variety of elements, and in eight domains of WHO’s framework for quality of which the behaviour of each is responsive to the maternal and newborn health care and refers to actions of others within the system (adaptive); care that includes the right to dignity; respect; interactions are nonlinear; and responses or 23,26,28 privacy; confidentiality; equality; informed con- changes are unpredictable (complex). 5,19 sent; autonomy; and timeliness. Additionally, Table 1 shows a brief description of selected com- within the 2018 WHO Intrapartum Care for Positive plex adaptive system concepts. Nonlinearity refers Childbirth Experience recommendations, RMC is to the heterogeneous and multiple levels of inter- recommended to improve the quality and action between system agents which makes sys- 8 26,30 woman-centredness of care during childbirth. tem behaviour unpredictable. Small changes In addition to framing these recommendations, in inputs may lead to large changes in outputs. there should be a mechanism for fostering Conversely, large changes in inputs may result in 20 28 accountability to achieve sustainable change. small changes in output. Gear and colleagues These efforts need to happen in the context of describe feedback loops as “recursive mechanisms comprehensive quality of care improvements, arising from multiple agent interactions over time including the technical dimension. that either reinforce (positive) or undermine 457 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 (negative) each other. Positive feedback loops sup- Table 1. Description of important port a change trajectory while negative feedback concepts loops tend to undermine or negate change”. When system elements interact, the system dis- Concepts Description* plays a new aggregate behaviour that cannot be seen at the individual element level. This property Complex adaptive A type of system which comprises 23,26 is called emergence and such repeated inter- system diverse agents (complex), and where the behaviour of each actions over time make the system adapt to the agent is responsive to the behaviour of its elements; this is labelled as self- interactions with other agents organisation. Sometimes, past system events or within the system (adaptive) circumstances manifest their desirable or undesir- able influence on current system behaviours or Self-organisation The way in which agents interact 30,31 events – path dependence. to coordinate their own forms, or Despite the recent attention, evidence on the patterns of behaviour arising effectiveness of RMC interventions is meagre from repeated agent interactions over time both in Ethiopia and globally. Identifying the health system constraints to the promotion of Nonlinearity The heterogeneous and multiple RMC would contribute to the development of evi- levels of interaction between dence-based approaches. Our qualitative study agents which makes agent was undertaken to provide a better understanding response unpredictable of health system constraints to the promotion of RMC in Ethiopian hospitals. We aim to contribute Feedback loop Recursive mechanisms as a result of multiple agent interactions to the body of evidence that can be used in the over time that create reciprocal design and implementation of RMC programs in behaviour either reinforcing Ethiopia and other similar settings. (positive feedback loop) or undermining (negative feedback loop) each other Methods This study is part of a broader mixed-methods Emergence New system behaviours (larger intervention study which was conducted entities) generated by the between March 2018 and August 2018 to explore interactions of smaller or simpler entities health system factors influencing RMC and to develop and assess mitigation approaches in Path Dependence Past experiences influence the southern Ethiopia. The study was conducted in responses to new events collaboration with the Federal Ministry of Health and the Southern Nations Nationalities and System hardware Constituent of health system that Peoples Region (SNNPR) Health Bureau, Ethio- includes human resources, pia. This paper reports on the qualitative com- financing, technology, service delivery, infrastructure, and ponent of the study exploring the health supplies system constraints to implementing RMC. We used the WHO’s health system building blocks System software Constituent of health system that (service delivery, health financing, leadership includes tangible (leadership, and governance, health workforce, medical management, and governance technologies, and health information) to ident- knowledge and skills, rules and ify the constraints. procedures) and intangible (values and norms, power Study setting relationships, and information communication) elements that According to the three-tiered Ethiopian health interplay with system hardware service system, primary hospitals, along with elements to influence the system their catchment health centres and health posts, constitute the first tier. Primary hospitals *Source: Modified from Braithwaite et al. ; Gear 26 23 33 are designed to provide primary level services et al. ; Gomersall et al. ; and Sheikh et al. . with a minimum capacity of 35 beds and 24-h 458 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 emergency services, including comprehensive primary and referral facilities. The hospitals emergency obstetric care. In the second tier, admit women with or without a referral for both there are general hospitals which provide the normal and caesarean delivery services and same services as primary hospitals, but have share similar characteristics with other hospitals over 50 beds, and are designed to provide a of their levels in the country. See Table 2 for pro- range of specialist services including gynaecology files of the study hospitals. and obstetrics, paediatrics, internal medicine, The intervention surgery, psychiatry and emergency services, and include diagnostic facilities and therapeutic The rationale for this intervention arises from the interventions. Specialised hospitals form the lack of (1) a stand-alone RMC promotion package third tier and serve as referral centres for general in Ethiopia and (2) evidence on the effectiveness hospitals. and implementation challenges of RMC interven- The study was conducted in three public hospi- tions in Ethiopia and globally. There were three tals (two general and one primary hospital) and components to the RMC intervention: a three- their corresponding programme administrative day offsite staff training on RMC; placement of units. The hospitals were selected based on the wall posters in labour wards; and onsite suppor- primary author’s familiarity with the settings tive supervision. The intervention focused on the and intention to have an appropriate mix of interpersonal aspect of care, including the Table 2. Profiles of study hospitals Characteristics Hospital I Hospital II Hospital III Geographical and population profile (2017) Location (urban/rural) Urban Semi-urban Semi-urban Catchment population 359,358 261,271 267,589 Expected pregnancies in the catchment 12,434 9,040 9,259 Number of public hospitals in the catchment (including 03 01 01 current one) Number of health centres in the catchment 05 09 11 Facility profile Total number of births attended in the last quarter of 2017 1081 433 713 Total number (%) of caesarean births in the last quarter of 164 (14.9) 62 (14.3) 138 (19.4) Upgraded from a lower-level facility (Yes/No) Yes Yes No Number of labour wards 02 01 01 Total number of beds in the labour ward 10 (5 in each) 05 05 Number of delivery rooms 01 01 01 Total number of birthing beds in the delivery room 04 04 3 Type of delivery room (Partitioned/Non-partitioned)* Non- Non- Non- partitioned partitioned partitioned Number of functional showers in the labour ward 0 02 01 Number of functional handwash basins in the labour ward 01 02 01 Designated waiting area for accompanying family members Yes Yes Yes (Yes/No) *Open plan with multiple beds per room with no curtains/partitions. 459 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 recommendation for the admission of birth com- Focus group discussions panions, but did not involve structural or hard- Participants of the FGDs were service providers ware components. Further detail about the who provide care during labour, childbirth, evaluation of the intervention from women’s and immediate postpartum periods in the and service providers’ perspectives is available in maternitycare unitofthe studyhospitals.The 36,37 other studies published elsewhere. pre-RMC intervention FGDs were conducted in Implementation of the whole set of components three public hospitals; two FGDs were conducted of the intervention lasted for three months. All in one of the hospitals, while one FGD was con- service providers who assist women in the study ducted in each of the other hospitals. A total of hospitals (n = 69) were invited to participate in 32 participants took part in the pre-RMC inter- the intervention. Eventually, 64 service providers vention FGDs (6–10 participants in each FGD); received all the intervention components includ- 24 of the participants were female, while the ing the training; five service providers did not remaining 8 were male (Table 4). A total of 21 attend the training for personal reasons. The par- participants took part in the post-RMC interven- ticipants comprised 51 midwives (79.7%), 4 gen- tion FGDs (6–8participantsin eachFGDs; 1 in eral practitioners (6.3%), 4 integrated emergency each intervention hospital) that were conducted surgical officers (6.3%), 3 nurses (4.7%), and 2 two months after the intervention; 15 of the health officers (3.1%); 44 (68.8%) were female participants were female, while the remaining and a similar percentage were aged between 22 6 were male. Participant selection for the pre- and 29 years. Table 3 shows details of the com- intervention FGDs was conducted based on the ponents and participants of the intervention. availability of service providers and depending The RMC intervention goes in line with the core on their duty assignment. The maternity care themes of the caring, respectful, and compassio- unit coordinators invited all service providers nate (CRC) health workforce initiative, one of the who were not on day-time duty and those who four transformation agendas of Ethiopia’s Health turned up were included. All participants (32) Sector Transformation Plan (2015–2020). A of the pre-RMC intervention FGDs received the 2019 government review indicated that lack of RMC training, making 50% of the RMC training ownership and engagement of stakeholders at participants. For the post-RMC intervention all levels, lack of system-wide implementation, FGDs, candidate participants (those who lack of finance, weak monitoring and evaluation attended the RMC training and who were not systems, lack of research and evidence in the on day-time duty) were invited to participate field, and resistance among providers were in an FGD (Table 4). The pre-intervention FGDs among the key challenges in implementing the were conducted to explore the knowledge of ser- initiative. While the CRC initiative is generic vice providers on quality maternity care, RMC, and designed for the entire health service in the and the mistreatment of women; health system country, it lacks depth and focus to address the challenges; service providers’ experience in the core themes of RMC. In contrast, the study inter- provision of RMC; the contributors to the mis- vention dealt with promoting all components of treatment of women in health facilities; de/ the RMC charter and involved the mechanisms motivators of RMC provision; and seek for their to track progress and take improvement actions. recommendations of what needs to be done to improve RMC. The post-intervention FGDs explored the challenges service providers experi- Sampling and recruitment enced during implementation of the RMC train- We conducted 7 focus group discussions (FGDs) ing and further actions required to promote with service providers (4 FGDs before the RMC RMC. intervention and 3 FGDs after the RMC interven- The preliminary analysis of the formative data tion) and 12 in-depth interviews (IDIs) with key set – 4 pre-intervention FGDs and 12 pre-interven- informants. As the IDIs aimed to explore the status tion IDIs – helped us to contextualise the RMC of respectful care in the hospitals and existing training, notably the addition of a consultative challenges to providing RMC from the perspectives discussion with training participants, hospital of key informants who hold a managerial position, administrators, and programme managers on all were conducted before the RMC intervention. the last day of the training sessions. 460 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Table 3. Description of the RMC intervention Component Description Participants Intervention period RMC training The RMC training manual 64 service providers at the First round: included contents on an overview participating hospitals who 25–27 April 2018 of maternal health in Ethiopia; assist women during Second round: 2–4 May 2018 human rights and law in the childbirth (in two rounds) context of reproductive health; RMC rights and standards; professional ethics; and continuous quality improvement. The manual was designed after a thorough review of RMC implementation programmes in Kenya, Tanzania, and Nigeria; and WHO’s recommendations of Intrapartum Care for Positive Childbirth Experience; and national guidelines and professional ethics codes. Wall posters Four wall posters All (64) training participants 25 April–4 May 2018 The universal rights of The wall posters were Posters were handed over to childbearing women prepared included in the RMC training the hospitals’ MCH by the White Ribbon Alliance manual and all participants coordinators at the end of (one poster) were briefed on these. the second round training Infographics taken from the session. intrapartum care for a positive childbirth experience guideline prepared by the WHO (three posters) Onsite Two rounds of post-training All (64) service providers who First round: June 2018 supportive quality improvement supportive attended the RMC training. Second round: July 2018 supervision supervision were conducted to (There were service providers appraise the action plan who attended both rounds of implementation, and to set the supervision.) actions for the next cycle with the long-term aim of developing a culture of continuous quality improvement actions. Guidance on a facility-led assessment of RMC using a structured checklist that was part of the RMC training manual. Guidance on action plan development to address actionable gaps identified by the assessment checklist. In-depth interviews programme levels. Key informants at the hospital All IDIs were conducted before the RMC interven- level were maternal and child health coordina- tion with key informants at hospital and tors, institutional quality focal persons, medical 461 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Table 4. Summary of participants and topic areas investigated during FGDs and IDIs No. of FGDs/ Category Facility IDIs Total no. of participants* Topic areas explored Pre- Hospital I 2 16 (14 midwives, 2 nurses) Features of quality maternity care; intervention twice and perception of Hospital II 1 8 (7 midwives, 1 integrated FGDs mistreatment; twice and perception emergency surgical officer) of respectful care; contributors to mistreatment; challenges Hospital III 1 8 (7 midwives, 1 health officer) experienced in labour wards; motivators and demotivators to provide respectful care; actions required to promote respectful care Post- Hospital I 1 7 (6 midwives, 1 nurse) Perceived behavioural influences of intervention the training; challenges encountered, Hospital II 1 8 (8 midwives) FGDs and new behaviours emerged in implementing the training; additional Hospital III 1 6 (5 midwives, 1 general actions required to implement the practitioner) training; partakers of RMC Pre- Hospital I 4 4 (MCH** coordinator, quality Features of quality maternity care; intervention focal person, medical director, twice and perception of IDIs and chief executive officer) mistreatment; twice and perception of respectful care; contributors to Hospital II 4 4 (MCH coordinator, quality mistreatment; perceived status of focal person, medical director, respectful care; respectful care and chief executive officer) initiatives; challenges in advancing respectful care Hospital III 3 3 (MCH coordinator, quality focal person, and medical director) Regional 1 1 (senior maternal health health expert) bureau *Most FGD participants were midwives because 80% of service providers who assist women during childbirth in the study hospitals were midwives. **MCH: Maternal and child health. directors, and chief executive directors of the Data collection three intervention hospitals. The programme Pre-intervention FGDs and IDIs were conducted level IDI was conducted with a senior maternal from March 2018 to April 2018, and post-interven- health expert at the SNNPR Health Bureau tion FGDs were conducted in July 2018. Initially, (Table 4). The key informants were selected aim- semi-structured interview guides were developed ing at obtaining rich information from both hospi- in English after a thorough literature review. The tal and programme levels that could enable us to key topic areas explored during the FGDs and meet the study objective. The IDIs explored the IDIs are presented in Table 4. The FGDs lasted constraints to the promotion of RMC from the per- 45 minutes to one hour while the IDIs lasted spectives of programme managers and adminis- 20–30 min. trators who look after the programming and The guides were then reviewed for content and operation of maternal health services at hospital, clarity by two of the co-authors. The primary zonal, and regional levels. author translated the final version interview 462 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 guides for both the FGDs and IDIs into Amharic Ethical considerations language and used these versions to collect data Ethical approval for this study was obtained from in Amharic. Data were collected and digitally the University of Melbourne (Australia) and the audio recorded by the primary author, who is SNNPR Health Bureau (Ethiopia). Participants familiar with the local context. Participants were were given a plain language statement about the provided with compensation for local study that they read before consenting to partici- transportation. pate; all participants gave written consent before participating in the study. Data analysis The primary author did the simultaneous trans- lation (from Amharic to English) and transcription Findings and interpretations of the audio recordings. The transcribed data were We identified seven health system factors influen- then imported into NVivo software (QSR Inter- cing the promotion of RMC belonging to the cat- national, Version 12 Plus) for analysis. Data from egories of system hardware (bed availability; the pre-and post-intervention FGDs and IDIs infrastructure and supplies; financing; and health were analysed concurrently. Data were coded workforce) and system software (staff motivation; inductively and deductively using standard quali- service providers’ mindset; and awareness of tative methodology, and analysed in two steps, RMC). These elements exhibited complex inter- first inductively to identify themes emerging actions with each other, amplifying the challenges from the transcripts and then deductively using of implementing RMC. Limited responsiveness the complex adaptive systems theory. Addition- within the maternity care system constrained ally, complexity theory helps to synthesise the implementation of the RMC recommendations. constraints to RMC through the lens of inherent In the following sections, we report on the system organisational complexities in hospitals; evidence interactions by identifying where complex adap- from such synthesis can later be translated to tive system processes were at play, which are tackle implementation problems. Coding of depicted in Figure 1. Consistent with complex sys- data was undertaken by the primary author tems, some of the themes have shared causal fac- after reading and rereading the transcripts to tors and intersect with each other. identify themes that impede RMC; the themes were then reviewed by one of the researchers Bed availability (AM). The agreed-upon themes were then grouped All study hospitals have only one labour ward and into either system hardware or system software one delivery ward (separate from the labour ward) categories, according to Elloker et al. In this con- where women stay together; there are four to six text, system hardware refers to supply, health hospital beds in each labour ward and three to workforce, facilities, and financing, whereas sys- four birthing beds in each delivery room (Table tem software refers to knowledge and mindset, 2). In response to the rising client flow, one of referral system, support and motivation, and ser- the hospitals had previously built a new maternal vice delivery guidelines. Following the thematic and child health unit which helped to separate analysis, we used complex adaptive system theory obstetrics and gynaecology wards while the as a framework to explore and map the complex remaining two have renovated their labour interactions within and between the system hard- wards to accommodate more beds. ware and system software elements. This approach of data- and theory-driven analysis is “We are restructuring the wards using partition suggested by scholars to improve rigour in the- boards to add two more beds. As a long-term sol- matic analysis. The primary author developed ution, we are constructing a new hospital building a causal loop model using Vensim software to that will take about two years to be available for visualise the interactions between different sys- service.” (Coordinator, Hospital I) tem elements in the maternity care system that Despite these facility-level remedies to increase affect the delivery of RMC. The developed model bed capacities, all study hospitals experienced was then reviewed by all authors. We used the patient numbers that exceeded bed capacity: consolidated criteria for reporting qualitative research to report important aspects of this “… the main challenge is the shortage of beds, study. especially during the night-time; there is a huge 463 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Figure 1. Causal loop diagram of factors influencing respectful maternity care in hospitals* Notes: “+” sign on the blue arrows indicates the causing variable increases the outcome variable. “−” sign on the blue arrows indi- cates the causing variable reduces the outcome variable. “R” in the red rotating arrows indicates the variables have a reinforcing effect on each other in the direction of the arrow. complaint from staff and the community in this bypass health centres, assuming that they will regard. Sometimes, it is the gatekeepers who tell receive better service in hospitals, an important women coming by ambulance to turn around and factor explaining the shortage of beds and over- look for other hospitals in the city.” (Coordinator, crowding in hospitals. Participants also said that Hospital I) many women are referred from lower-level facili- ties without any clinical indications requiring Although women can give birth in lower-level referral and could have given birth safely at pri- health facilities, participants reported that most mary level health services and that bypassing women who come to hospitals for childbirth these facilities increases pressure on the hospitals. 464 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 “More than half of the women who give birth in our women. As a result, service providers faced a hospital can give birth at health centre levels. dilemma of which aspect of RMC to prioritise – Women bypass these facilities, and there is also privacy or labour companionship. Eventually, an inappropriate referral of women from these labour companions were denied admission in facilities. Last month, 59 women who were referred labour wards, especially in two of the hospitals, from ‘health centre A’ gave birth in our hospital because of the privacy concerns. without any particular procedure for an assisted “Because we do not have adequate [privacy] delivery (vacuum or forceps). ” (Coordinator, Hospi- screens, we are asking all labour companions to tal III) go out of the ward whenever a woman is to have In response to the overcrowding, health workers an examination …” (Service provider, post-RMC are faced with the following choices to manage intervention FGD, Hospital III) excess client flow: admitting women who are in The interaction between the lack of privacy and labour to wait in corridors until someone gets dis- the admission of labour companions in labour charged, or referring women to other facilities, wards proved to be competing forces, a manifes- including those who have already been referred tation of non-linear inter-relationships. Service to them from other facilities. providers’ understanding of privacy seemed to extend only to the companions of other women Infrastructure and supplies in the ward, not to the other women (residing) In all hospitals, in addition to the overcrowding in the ward, who are also strangers. This implies described above, there were both space con- privacy is still lacking, although the degree may straints and supply shortages. The absence of priv- be less than when companions are in the room. acy screens was a key constraint to the provision of In a different context, there might be a positive respectful care, especially maintaining women’s relationship between the presence of labour com- privacy during vaginal examinations. In the two panions and RMC, but in a context in which avail- upgraded hospitals, there was only limited expan- able supplies, especially privacy screens, were sion of the labour wards, delivery rooms, and often lacking, the expected relationship is modi- waiting areas for families, meaning that the reno- fied and effectively reversed. In effect, this par- vations have not equipped the hospitals with ade- ticular hardware issue is among the key system quate space given the expansion of services. elements jeopardising RMC. Other supply issues identified were the short- “This hospital was a clinic 57 years ago; it was then age of bed linen; infection prevention supplies upgraded to a health centre and later to a primary including aprons, gloves, soap and chlorine sol- hospital and then general hospital without signifi- utions; blood packs; essential medicines including cant expansions. That is why the buildings/rooms ergometrine; and foetal monitoring equipment. are not conducive to provide services to the level Furthermore, lengthy procurement procedures that a general hospital should do.” (Manager, Hos- and the supply of low-quality medical equipment pital I) were additional challenges to the continuous Following the RMC training, all hospitals allowed availability of supplies: labour companions to accompany women in “… a respectful midwife cannot address all labour wards, which meant there were several requirements of respectful care alone. He/she companions in one labour ward. The willingness must be provided with required supplies …” (Coor- among staff indicates that there is a real opportu- dinator, Hospital II) nity to promote labour companionship in the long run. However, participants said that it was chal- In the case of acute stockouts of recurrent lenging to maintain women’s privacy during vagi- supplies, hospitals adapted to these situations by nal examinations because there are several commissioning special purchase of supplies “strangers” in the labour wards which are already using their internal revenue, asking for support considered small, given the number of beds they from non-governmental partner organisations, accommodate, as indicated in Table 2. Thus, and borrowing from nearby health facilities. To while the admission of labour companions likely initiate an independent purchase of missing benefited women during labour, it simultaneously supplies mentioned above, hospitals require an had an undesirable effect on the privacy of other 465 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 out-of-stock clearance from the Ethiopian entitled to get from hospitals.” (Coordinator, Hospi- Pharmaceutical Supply Agency. Once hospitals tal III) are granted permission, meeting the require- The fee-exemption was introduced first in health ments of government procurement guidelines centres and then in hospitals between 2005 and was reported to be very challenging. 2010. In principle, hospitals apply to the Ministry “We have allocated a budget for the purchase of of Health at the end of every quarter for reimbur- supplies. However, it is tough to get these in the sement for the costs incurred to deliver fee- market. How could I admit a woman for labour exempted services. While the fee-exemptions when I do not have a glove to use? A mother will were regarded as positive in promoting equity, get referred without her will and consent …” (Man- challenges arose to meet the expectations for ser- ager, Hospital I) vices. For example, delays in reimbursement were reported in all hospitals and contributed to supply Additionally, participants described several facility shortages because hospitals were not able to constraints including dysfunctional or complete accumulate funds that they could use for procure- absence of utilities like shower and sinks, shortage ment. We identified an emergent behaviour in of water supply, no waiting area for companions, response to the implementation gap of the fee- and poorly ventilated wards. These challenges exemption policy for maternal health services – were also the reason why service providers did requesting women to buy supplies: not allow women and their families to perform cultural ceremonies/practices that they would do “… now, we are in the second quarter of the cur- if the woman had birthed at home. Hospital rent budget year. However, we did not yet get reim- administrators have indicated that they have bud- bursed by the Ministry for our expenses of the get limitations for regular maintenance and reno- second quarter of the previous budget year. We vation works. Accordingly, the supply and facility are in a big challenge currently.” (Manager, Hospi- constraints in the hospitals were influenced by tal II) complex interactions between various agents such as leadership, governance, and financing, Insufficient and delayed release of budgeted which are complex systems themselves. funds were the two other key challenges affecting These supply, space, and facility constraints the management and delivery of childbirth ser- have direct (denying women the required level vices in the hospitals. The beginning of a fiscal of services and resulting in unnecessary referrals) year is the most challenging period when hospi- and indirect (damaging providers’ commitment tals encounter difficulties in paying compensation to provide care due to health and safety concerns) for services such as night and weekend duties, as negative effects on RMC. the new fiscal year’s budget is not usually released for use on time. Consequently, service providers wait for months to get paid for their weekend Healthcare financing and night duties, and this has resulted in demoti- vation of service providers and a negative relation- All hospitals were implementing a financing rec- ship between service providers and ommendation set forward by the Ethiopian gov- administrators. ernment to make antenatal, delivery, and Financial bottlenecks also resulted in the postnatal care services available free of charge assignment of a substandard number of midwives in public health facilities although there were for night and weekend duties to minimise some inconsistencies before the CRC initiative. expenses. As such, the assigned service providers As part of the government’s initiative to promote bear a higher workload than they are supposed CRC, the hospitals waived the fee for investigations to; this often leaves them frustrated and even- conducted during pregnancy and childbirth, tually results in the mistreatment of women. including obstetric ultrasound. “… in some hospitals and most health centres, an “Investigations, including ultrasonography, for adequate number of midwives are not assigned women are provided free of charge with a special for night duties; this practice is totally against the consideration not only to make them happy and standard, and it happens because health facilities encourage them to give birth in health facilities do not want to pay for night duty. There are but also to provide the services that they are 466 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 occasions five or more labouring women come in a Hospital administrators reported that they use the single night, and the workload makes us ‘health national pay scale, and they do not have the auth- providers’ to behave disrespectfully.” (Service provi- ority to adjust salaries and other payments how- der, pre-RMC intervention FGD, Hospital I) ever they share providers’ complaints. These complex interactions between different “Because what is being paid here is low, service pro- agents in the financing system left hospitals in viders look for part-time jobs elsewhere. That, in financial bottlenecks which in turn added to the turn, compromises the quality of service in our hos- complexity in the maternity care system (affecting pital as service providers get fatigued … I know this the availability of supplies, deployment of ade- is a national problem and cannot help it …” (Coor- quate staff, timely payment of remuneration, dinator, Hospital I) etc.), making it difficult to practice RMC. The Midwives reported that there is an unfair gap of delay in providers’ night and weekend duty pay- risk allowance among different professions; mid- ments made providers feel disrespected, further wives report receiving 470 birr (∼17 USD) per compounding the complexity of RMC delivery. month while health officers and emergency nurses receive a higher risk allowance, 1250 birr Staff motivation (∼46 USD) and 1200 birr (∼44 USD), respectively. As part of the CRC initiative, all hospitals have Managers have also expressed the gap as inap- introduced staff appraisal and recognition cer- propriate and creating dismay among midwives. emonies which occur every six months to give Midwives claimed that they are exposed to a awards to the best performing staff from each higher level of professional risk, such as infec- unit of the hospitals, including maternity units. tions, compared to health officers and emergency The coordinator of one of the hospitals reported nurses. Because of these dissatisfactions, the lack that they also have a fortnightly coffee ceremony of career opportunities, and the relatively better in which women and their families are involved pay that other non-health professional graduates and best practices and gaps identified are dis- (such as accountants) of the same years of employ- cussed. This recognition was important to improve ment receive, participants said that fellow mid- staff morale. wives are leaving the profession. “… there are CRC focal persons in each unit who “Practicing midwifery is difficult in Ethiopian facili- appraise respectful care, deal with breach of pro- ties; as a midwife, you are supposed to work for 24 fessional ethics, and hold group meetings with hours if you have night duty, the workload is excep- their team. The best performer professional is tionally high, you take care of several women at a selected every six months from each unit, and a cer- time. Disproportionately, your salary is very low, tificate of appreciation is awarded to motivate as is your risk payment.” (Service provider, pre- them.” (Coordinator, Hospital I) RMC intervention FGD, Hospital II) However, there were simultaneously weak staff The interaction between high workload and attri- incentives and a lack of motivation schemes in tion of midwives exhibited a positive feedback hospitals, which had a negative effect on RMC by loop: the more midwives resign, the higher the damaging providers’ enthusiasm to provide workload becomes, which in turn leads the respectful care. These included: low salaries; risk remaining midwives to resign. This emergence of allowance gaps among professions; lack of sup- behaviour (resignation) among midwives due to port and recognition by managers; lack of career the longstanding problem of staff motivation, opportunities; undefined career path (especially including a lack of career path, further makes for midwives and integrated emergency surgical the delivery of RMC complex. Given the shortage officers); low and delayed remuneration for of midwives in the country, such preventable attri- night and weekend duties; and lack of a positive tion would again add to the complexity of health work environment. workforce availability and quality and is a barrier “Sometimes, you keep on doing and discharging to promoting RMC. your responsibilities appropriately, but no one Health workforce from the senior managers comes to you and sees what you do and gives you recognition.” (Service Both program coordinators and administrators provider, post-RMC intervention FGD, Hospital I) emphasised that the shortage of staff, especially 467 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 midwives and obstetrician-gynaecologists, needs were mistreating women intentionally and to be resolved if respectful care is to improve. Hos- unintentionally. pitals recruit obstetrician-gynaecologists on a “Junior professionals adopt behaviour of their short-term and often expensive contract basis to seniors. The trend so far was distancing and hierar- fill the acute shortages of these specialists, and chy between different professionals and between that is draining their revenues. professionals and patients; that finally leads to A manager of one of the hospitals reported that the designation of providers as “bosses” who order obstetrician-gynaecologists do not want to work patients what to do.” (Coordinator, Hospital III ) on a permanent basis in order to take advantage of the higher salary, sometimes more than three “… there is a wrong tradition of regarding health times the regular salary that hospitals offer on a professionals as kings among service users; ‘no contract basis. The more the hospitals pay for con- one can talk to them’ type of thought. That resulted tract-based recruitment, the less likely specialists in some providers feeling proud of their professional are to take full-time positions. status and undermining others …” (Manager, Hos- The shortage of professionals has created an pital II) increased workload, fatigue and negligence, The post-intervention FGDs revealed that some unnecessary referrals, and failure to respond to providers have reservations about the feasibility women’s preference of service providers. Dissatis- of fully respecting the universal rights childbear- faction with the work climate and dysfunctional ing women should have in health facilities. Provi- professional hierarchy, in addition to the low ders reported that the rights of women could not pay, were also identified as the key reasons for be entertained given the existing multidimen- the high turnover of service providers in the sional constraints reported in this study. Addition- hospitals. ally, providers required their rights also be “… It is the standard to have two providers for a defined and guaranteed. labouring woman; one for the mother and one for “… in 99% of the cases, health facility management the newborn. However, we do not practice that attend only to the rights of clients; they do not always since there is a shortage of workforce … emphasise the rights of professionals …” (Service this makes providers nervous at the end.” (Coordi- provider, pre-RMC intervention FGD, Hospital I) nator, Hospital III) After the RMC training, some providers opposed the distribution of a pamphlet on The Universal Service providers’ mindset Rights of Childbearing Women (Amharic version) that had been endorsed by the Ministry of Health. Service providers who participated in the interven- Eventually, none of these pamphlets were distrib- tion showed a willingness to implement practices uted. Participants said that women and their com- to support RMC. These included allowing support panions demand to exercise the rights included in by labour companions, allowing women to birth the pamphlet and that providers are not able to in their preferred position, and seeking women’s address these due to system hardware constraints consent before procedures, and reflected a level despite most rights on the declaration being of agency amongst the staff and a commitment related to interpersonal care. to quality improvement initiatives. “… we used to provide care with force if women “… for example, I had a long night assisting refused to have a procedure or an examination. women, but I am not paid fairly. Is it fair to accuse After the training, there is no such practice; we pro- me of violating women’s rights? I do not think … a vide services with consent and respect.” (Service lot must be done from top to bottom in responding provider, post-RMC intervention FGD, Hospital II) to providers right before trying to maintain women’s right.” (Service provider, post-RMC inter- Yet health workers also faced entrenched inter- vention FGD, Hospital III) personal hierarchies of care that constrained Even after receiving the RMC training, some ser- RMC. Because of an intergenerational trend of vice providers continued to express the idea that hierarchical patient-provider and provider-provi- it is acceptable to disrespect women when provi- der relationships and the lack of awareness of ders are not also respected. the constituents of RMC, participants said they 468 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Awareness of RMC the lessons learned through its implementation, including the enablers of RMC (mixed-methods Before the RMC training, RMC was a new terminol- study among service providers who participated ogy to participants of the FGDs and IDIs; similar in the intervention). The survey of women were “mistreatment” and “disrespect and revealed that the number of mistreatment com- abuse”. Participants had an awareness of what ponents women experienced during childbirth in respectful care means, mostly in its interpersonal the study hospitals was reduced by 18% after the aspect, while they lacked awareness of its systemic RMC intervention. The mixed-methods study aspects. As supported by participants of the post- revealed that service providers’ awareness of the intervention FGDs, short-term RMC trainings like rights of childbearing women, perceptions and the one implemented in this study play a key attitudes about RMC, and motivation to provide role in improving service providers’ awareness of respectful care improved after the RMC RMC and the rights of childbearing women in intervention. health care settings. To our knowledge, this is the first study to “I am now aware that I may disrespect women in explore the status of RMC through the theoretical various ways. On the other hand, I have also under- lens of complex adaptive systems, which allowed stood that I can serve women very nicely and make us to focus both on structures and functions (pro- them satisfied with little efforts. I have also learned cesses) of the maternity care system and the inter- what makes women displeased.” (Service provider, play between these. We have synthesised the post-RMC intervention FGD, Hospital II) findings of this study using a causal loop diagram that shows the complex relationships between Participants recommended that support staff who different system elements in the RMC system have a direct or indirect role in maternity care, (Figure 1). including the reception at the hospital entrance The interaction between system hardware and gate, should also receive the training, with the jus- software constraints in maternity settings was com- tification that RMC cannot only be achieved by the plex and warrants a systems approach to improve care in maternity wards. A programme coordina- RMC. A system constraint can affect both clinical tor at the regional level outlined that there is a and non-clinical maternity care components at gap in knowledge of RMC because the existing ser- the same time or may have spill-over from one of vice delivery guidelines lack content on RMC. these components to another due to the existence of interactions between the components. Simi- Discussion larly, an intervention component that aims at Service providers’ lack of knowledge of RMC and improving a system component may have a posi- an unconscious normalisation of disrespectful tive or negative consequence on other com- care highlights the need for tailored RMC edu- ponents. For example, weak implementation of cation. Nonetheless, it is important to emphasise the fee exemption for maternity care services the non-behavioural challenges that also need to resulted in a lack of revenue and supply shortages be addressed to ensure that knowledge is trans- in the hospitals; in response, women were asked to lated into practice. We conducted this study to buy supplies in direct contradiction to the policy. outline the system constraints to the promotion Not only is this disrespectful, but it may also offset of RMC in public hospitals from the perspectives the intended aim of the fee removal, which is to 46,47 of service providers and managers. The pre- and improve service utilisation. post-RMC intervention qualitative enquiries bene- System hardware and software constraints chal- fited this study in identifying the complex inter- lenged the implementation of RMC recommen- actions between various system elements in the dations. For example, financial limitations in the absence of and with the intervention. Notably, study hospitals led to a complex relationship the post-RMC intervention FGDs helped to demon- affecting recruitment and motivation of staff, strate how the interaction between various system availability of supplies, and maintenance of facili- constraints could mark the implementation of ties. A study from Kenya also demonstrated that RMC recommendations. financial limitations negatively impacted service In two other studies, we have reported on the providers’ and hospital administrators’ motivation evaluation of the RMC intervention (survey of to implement hospital initiatives. According to women before and after the intervention) and Clark, such complex problems necessitate 469 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 complex interventions (interventions that encom- facilities and to build communities’ confidence pass different parts such as financing, supply, in these facilities. Without these actions, improv- workforce, infrastructure, and others) but cannot ing RMC only in hospitals means more women be solved by behavioural interventions alone. keep on bypassing primary facilities because of Therefore, as outlined by the WHO, implementing preferences for hospital-level care in the commu- context-based complex interventions to improve nity, generating factors which impede improve- the quality of services is instrumental in promot- ment of quality of care in hospitals. ing RMC. While it is appropriate that regulatory and Evidence reviews report that having a labour financial control mechanisms aim at ensuring gov- companion during labour and childbirth helps ernance and reducing corruption in the health women to have a positive childbirth experi- system, they may also result in lengthy bureau- 50,51 ence. In this study, service providers encoun- cratic processes if poorly designed and/or tered the problem of sustaining practices of implemented, which can lead to disrespectful 35,58 admitting labour companions and allowing cul- behaviours among service providers. Nothing tural practices in labour wards, due to space and justifies disrespectful or abusive treatment of privacy constraints, and because an admission of women, but these working conditions make it companions inadvertently fed back negatively on more likely. A review by Reader and Gillespie the privacy of women. Such constraints are also reported that such institutional causes result in critical challenges in promoting the culture of normalisation of patient neglect and abuse labour companionship in health facilities glob- among providers and should therefore be ally. These constraints also indicate that addressed from both behavioural and organis- women’s privacy is already in jeopardy in the ational interventions. absence of adequate infrastructure. Addressing A noteworthy finding of this study is the impor- these barriers plays a crucial role in promoting tance of involving health managers in any health RMC and quality of care and contributes to the worker behaviour intervention. Service providers 53,54 improved uptake of maternity care services. reported being demotivated as they were improv- Furthermore, taking a contextualised and proac- ing services as per the RMC training guideline. Yet, tive approach to planning for health systems infra- no one from the facility management recognised structure improvement is required to improve the these efforts – a missed opportunity to keep up quality of care, mitigate the consequential and the enthusiasm for change. A study from Benin unintended impacts of innovations, and respond reported that management support and recog- to the evolving needs in LMICs, including nition of midwives and other staff was vital in sus- 3,49 Ethiopia. taining positive changes gained from a humanised Women bypass lower-level health facilities, as childbirth intervention. indicated in this study, due to lack of confidence Strengths and limitations in lower facility providers, perceived low-quality of service, and fear of referral processes in case Exploring service providers’ perspectives of apply- of a birth complication in lower-level facilities. ing new knowledge into practice is of paramount When this is coupled with the lack of bed capacity importance to plan for future interventions that in hospitals, it predisposes women to mistreat- can be applied in the real world. In this regard, ment by denying them the timely and quality the conduct of FGDs both before and after the care they deserve. It also results in a second refer- RMC intervention is the main strength of this ral and hospitals have to deal with client overflow. study as it profoundly helped us to have a richer A study conducted in three regions in Ethiopia understanding of how multiple interactions reported that 86.4% of patients visited hospitals between various system constraints could offset without referral, and bypassing was common the implementation of RMC recommendations among maternal and child health care seekers. and other similar quality improvement initiatives Similarly, a Tanzanian study also found that 44% in maternity settings. Additionally, the use of com- of women bypassed primary health facilities for plexity theory in the data analysis surpassed the childbirth mainly due to concern about the qual- depth of evidence that would be obtained by ity of care at health centres. It is, therefore, the traditional approaches of exploring single essential to improve the quality of maternity cause and effect relationships; it brought the care services in lower-level primary health wider picture of how various entities interact 470 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 with each other and directly or indirectly affect implementation of RMC from a health system RMC in the real-world setting. However, this strengthening viewpoint. We also recommend future study only reflects scenarios at primary and gen- implementation research in the field of RMC to eral hospitals and may, therefore, lack the bridge the discourse between theory and practice breadth to cover system constraints in referral in the local context. Finally, we believe that the find- and teaching hospitals and health centres in ings of this study inform policies and strategies to pro- Ethiopia. Additionally, since the post-intervention mote RMC in Ethiopia and other LMICs. FGDs were conducted two months following the intervention, our study is unable to explore how Acknowledgements systems adapted further after that point. In the The intervention part of this study was financially sup- current study, complexity theory was applied ported by the Institute for Healthcare Improvement post hoc for data analysis but did not guide the Ethiopia country office. The authors are indebted to development of data collection tools; this might the Federal Ministry of Health, the SNNPR Health have limited the completeness of the data col- Bureau, the Institute for Healthcare Improvement, lected and the opportunity to explore alternative the study hospitals, and Hawassa University College frames of analysis. Furthermore, participants of of Medicine and Health Sciences for their technical the post-intervention FGDs might have reported support during the conduct of this study. The authors their experiences of the RMC training in a way would also like to thank participants of the study for that would please the investigator who moderated their willingness to take part in this study. the FGDs, from social desirability bias. Funding The intervention part of this study was financially Conclusions supported by the Institute for Healthcare Improve- This study identified complex health system con- ment Ethiopia country office. straints that hinder the promotion of RMC in hospi- tals. Although quality of maternity care embodies ORCID both clinical and interpersonal aspects of care, this study highlights that interventions aimed at improv- Anteneh Asefa http://orcid.org/0000-0003-4470- ing only interpersonal or behavioural components 1848 fall short of mitigating the mistreatment of women Barbara Mcpake http://orcid.org/0000-0002- unless they also address the system-wide constraints. 9904-1077 As indicated in the study, there is scope for real Meghan A. Bohren http://orcid.org/0000-0002- improvement if the health system components are 4179-4682 part of the solution to promote RMC and end the mis- Alison Morgan http://orcid.org/0000-0001-5380- treatment of women. To enhance the status of 1619 maternal health in Ethiopia, we recommend the References 1. World Health Organization. Trends in maternal 4. Tuncalp Ö, Were WM, MacLennan C, et al. Quality of care mortality: 2000 to 2017: estimates by WHO, UNICEF, for pregnant women and newborns-the WHO vision. BJOG. UNFPA, World Bank Group and the United Nations 2015;122(8):1045–1049. Population Division. Geneva, Switzerland: World Health 5. World Health Organization. Standards for improving Organization; 2019. quality of maternal and newborn care in health facilities. 2. United Nations. Sustainable development goals. New York: Geneva: World Health Organization; 2016. United Nations Development Programme; 2015; Available 6. 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Implementation research Health. 2014;11(1):71. in health: a practical guide. Alliance for health policy 48. Barasa EW, Molyneux S, English M, et al. Hospitals as and systems research. Geneva: World Health complex adaptive systems: a case study of factors Organization; 2013. 473 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Résumé Resumen Les données sur les difficultés rencontrées par le En Etiopía y mundialmente existe evidencia limit- système de santé pour promouvoir des soins de ada de los retos que enfrenta el sistema de salud maternité respectueux sont restreintes en Éthio- para promover atención respetuosa de la materni- pie et dans le monde. Cette étude a enquêté sur dad (ARM). Este estudio investigó las limitaciones les obstacles du système de santé qui contrarient del sistema de salud con relación a la ARM en des soins de maternité respectueux dans trois tres hospitales de Etiopía meridional. Realizamos hôpitaux du sud de l’Éthiopie. Nous avons mené un estudio cualitativo (siete discusiones en grupos une étude qualitative (sept discussions par groupe focales con prestadores de servicios de ARM y 12 d’intérêt avec des prestataires de soins et 12 entre- entrevistas a profundidad con personas focales y tiens approfondis avec des agents de liaison et des administradores) antes y después de la ejecución gestionnaires) avant et après la mise en œuvre de la intervención de ARM. Posicionamos los servi- d’une intervention de soins de maternité respec- cios de atención durante el parto dentro del sis- tueux. Nous avons positionné les services d’obsté- tema de salud y aplicamos la teoría del sistema trique dans le système de santé et appliqué une adaptativo complejo para analizar las oportuni- théorie de systèmes complexes adaptatifs pour dades y limitaciones para promover ARM. Se iden- analyser les possibilités et les limitations de la tificaron los factores de “hardware” y “software” promotion de soins de maternité respectueux. del sistema que influyen en la promoción de Des facteurs aussi bien matériels qu’immatériels ARM, y su interacción era compleja. Los factores influençant la promotion de soins de maternité de “hardware” eran: disponibilidad de camas, respectueux ont été identifiés et leur interaction infraestructura y suministros, financiamiento y était complexe. Les facteurs «matériels» compre- fuerza laboral de salud. Los factores de “software” naient la disponibilité de lits, les infrastructures abarcaban la mentalidad de los prestadores de et les fournitures, le financement et le personnel servicios, la motivación del personal y la concien- de santé. Les facteurs «immatériels» englobaient cia de ARM. Un ejemplo de las interacciones entre l’état d’esprit des prestataires de services, la estos factores era el incumplimiento de privacidad motivation du personnel et la connaissance des de las mujeres al admitir acompañantes del parto soins de maternité respectueux. Parmi les inter- en las salas de parto. El reembolso retrasado actions entre ces facteurs figuraient des violations después de la introducción de exención de tarifas de l’intimité des femmes lors de l’admission d’ac- por servicios de atención de la maternidad causó compagnants dans les salles d’accouchement. Les agotamiento de ingresos, escasez de suministros y délais dans les remboursements après l’introduc- comportamiento irrespetuoso entre prestadores tion de l’exonération des frais pour les services de servicios. Otras limitaciones financieras, entre de maternité ont provoqué une baisse des reve- ellas la insuficiente y retrasada liberación de fon- nus, des pénuries de fournitures et, en finde dos, también propiciaron complejas interacciones compte, un comportement irrespectueux des pre- con la motivación del personal y la disponibilidad stataires. D’autres obstacles financiers, notam- de fuerza laboral y suministros, lo cual produjo ment le décaissement tardif de fonds incumplimiento de la orientación sobre ARM. insuffisants, ont aussi provoqué des interactions Las intervenciones destinadas a mejorar solo los complexes avec la motivation du personnel et la componentes conductuales no llegan a mitigar disponibilité du personnel de santé et des fourni- el maltrato de las mujeres. Para abordar las com- tures, ce qui a abouti à une piètre observance des plejas interacciones que limitan la ARM, es nece- conseils sur des soins de maternité respectueux. sario ejecutar intervenciones en todo el sistema. Les interventions visant à améliorer uniquement les composantes comportementales ne suffisent pas pour atténuer les mauvais traitements subis par les femmes. Des mesures englobant l’ensem- ble du système sont nécessaires pour s’attaquer aux interactions complexes qui limitent les soins de maternité respectueux. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Sexual and Reproductive Health Matters Taylor & Francis

Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

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Taylor & Francis
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© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
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1460-9576
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10.1080/26410397.2020.1854153
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Abstract

RESEARCH ARTICLE Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care a b c d Anteneh Asefa , Barbara McPake , Ana Langer, Meghan A. Bohren , Alison Morgan a PhD Candidate, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Assistant Professor, School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia. Correspondence: antex98@yahoo.com b Professor, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia c Professor, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA d Senior Lecturer, Gender and Women’s Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Carlton, Australia e Associate Professor, Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia Abstract: Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee- exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC. DOI: 10.1080/ 26410397.2020.1854153 Keywords: respectful maternity care, health system, complex adaptive system, system hardware, system software Introduction Africa. Key to achieving the sustainable develop- Despite the implementation of a range of ment goal target of reducing the global maternal maternal health interventions, maternal mortality mortality ratio to 70 per 100,000 live births by remains high in many low- and-middle-income 2030 is improving the quality of both clinical countries (LMICs), including those of sub-Saharan and non-clinical care women receive during the 456 © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduc- tion in any medium, provided the original work is properly cited. A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 time of pregnancy, childbirth, and in the immedi- Given the diverse contributors to the mistreat- 3 22 ate postpartum period. ment of women during childbirth, system com- The World Health Organization (WHO) defines plexity-informed strategies need to be designed the quality of care as “the extent to which health to advance context-specific and evidence-based care services provided to individuals and patient maternal health interventions. Although RMC, populations improve desired health outcomes” as a non-clinical aspect of quality care, relies on and outlines that safety, effectiveness, timeliness, the practice of service providers, it is open to efficiency, equity, and people-centredness of the interactions between other system com- health services are integral to achieving quality. ponents such as infrastructure, information and Applying this definition to maternal and newborn referral systems, financing, and motivation, 23,24 health services helps to view quality from two among others. standpoints: quality from the perspective of the Positioning RMC in a complex system helps to provision of care (clinical care) and quality from explore the constraints and patterns of interaction the perspective of how women and their families between system elements that directly or experienced the care (interpersonal care). Histori- indirectly affect the delivery of RMC in health cally, however, most quality improvement inter- facilities. In this study, the maternity care system ventions have focused on the clinical dimensions is regarded as a complex adaptive system. Accord- of maternity care while overlooking the interper- ingly, the concepts of complex adaptive systems sonal and social aspects of care. were used to guide data analysis and interpret- The mistreatment of women during facility- ation of the findings of this study. based childbirth has been reported as both a vio- The concepts of complexity science are rooted lation of women’s human rights and a significant in disciplines including biology, chemistry, phy- deterrent to the utilisation of skilled birth ser- sics, and sociology, among others. Consequently, 7–9 vices. Several studies from sub-Saharan Africa, several theories including evolutionary theory in including WHO-led studies, reported high biology, self-organisation theory in chemistry, 10,11 7,12 levels and diverse manifestations of the and chaos theory in mathematics contributed to mistreatment of women. Similarly, the worryingly the complexity science construct, the latter result- high level of mistreatment of women in Ethio- ing in a heightened interest in complexity science 13–16 pia highlights the need for a focused strategy among social scientists to study change, evolution, if the country is to improve maternal health and adaptive, and emergent behaviours in social and reduce maternal mortality. In 2019, only 47.5% organisational phenomena such as health- 27–29 of pregnant women gave birth in health facilities care. Complexity science resulted in the para- in Ethiopia although 74% of pregnant women digm shift from the linear cause and effect inquiry received at least one antenatal care visit from a underlying traditional formal approaches, to syn- skilled provider. A portion of this missed oppor- thetic reasoning and modelling of complex tunity may be addressed by preventing the mis- systems. 7,18 treatment of women. A complex adaptive system is a dynamic system Respectful maternity care (RMC) is one of the that consists of a wide variety of elements, and in eight domains of WHO’s framework for quality of which the behaviour of each is responsive to the maternal and newborn health care and refers to actions of others within the system (adaptive); care that includes the right to dignity; respect; interactions are nonlinear; and responses or 23,26,28 privacy; confidentiality; equality; informed con- changes are unpredictable (complex). 5,19 sent; autonomy; and timeliness. Additionally, Table 1 shows a brief description of selected com- within the 2018 WHO Intrapartum Care for Positive plex adaptive system concepts. Nonlinearity refers Childbirth Experience recommendations, RMC is to the heterogeneous and multiple levels of inter- recommended to improve the quality and action between system agents which makes sys- 8 26,30 woman-centredness of care during childbirth. tem behaviour unpredictable. Small changes In addition to framing these recommendations, in inputs may lead to large changes in outputs. there should be a mechanism for fostering Conversely, large changes in inputs may result in 20 28 accountability to achieve sustainable change. small changes in output. Gear and colleagues These efforts need to happen in the context of describe feedback loops as “recursive mechanisms comprehensive quality of care improvements, arising from multiple agent interactions over time including the technical dimension. that either reinforce (positive) or undermine 457 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 (negative) each other. Positive feedback loops sup- Table 1. Description of important port a change trajectory while negative feedback concepts loops tend to undermine or negate change”. When system elements interact, the system dis- Concepts Description* plays a new aggregate behaviour that cannot be seen at the individual element level. This property Complex adaptive A type of system which comprises 23,26 is called emergence and such repeated inter- system diverse agents (complex), and where the behaviour of each actions over time make the system adapt to the agent is responsive to the behaviour of its elements; this is labelled as self- interactions with other agents organisation. Sometimes, past system events or within the system (adaptive) circumstances manifest their desirable or undesir- able influence on current system behaviours or Self-organisation The way in which agents interact 30,31 events – path dependence. to coordinate their own forms, or Despite the recent attention, evidence on the patterns of behaviour arising effectiveness of RMC interventions is meagre from repeated agent interactions over time both in Ethiopia and globally. Identifying the health system constraints to the promotion of Nonlinearity The heterogeneous and multiple RMC would contribute to the development of evi- levels of interaction between dence-based approaches. Our qualitative study agents which makes agent was undertaken to provide a better understanding response unpredictable of health system constraints to the promotion of RMC in Ethiopian hospitals. We aim to contribute Feedback loop Recursive mechanisms as a result of multiple agent interactions to the body of evidence that can be used in the over time that create reciprocal design and implementation of RMC programs in behaviour either reinforcing Ethiopia and other similar settings. (positive feedback loop) or undermining (negative feedback loop) each other Methods This study is part of a broader mixed-methods Emergence New system behaviours (larger intervention study which was conducted entities) generated by the between March 2018 and August 2018 to explore interactions of smaller or simpler entities health system factors influencing RMC and to develop and assess mitigation approaches in Path Dependence Past experiences influence the southern Ethiopia. The study was conducted in responses to new events collaboration with the Federal Ministry of Health and the Southern Nations Nationalities and System hardware Constituent of health system that Peoples Region (SNNPR) Health Bureau, Ethio- includes human resources, pia. This paper reports on the qualitative com- financing, technology, service delivery, infrastructure, and ponent of the study exploring the health supplies system constraints to implementing RMC. We used the WHO’s health system building blocks System software Constituent of health system that (service delivery, health financing, leadership includes tangible (leadership, and governance, health workforce, medical management, and governance technologies, and health information) to ident- knowledge and skills, rules and ify the constraints. procedures) and intangible (values and norms, power Study setting relationships, and information communication) elements that According to the three-tiered Ethiopian health interplay with system hardware service system, primary hospitals, along with elements to influence the system their catchment health centres and health posts, constitute the first tier. Primary hospitals *Source: Modified from Braithwaite et al. ; Gear 26 23 33 are designed to provide primary level services et al. ; Gomersall et al. ; and Sheikh et al. . with a minimum capacity of 35 beds and 24-h 458 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 emergency services, including comprehensive primary and referral facilities. The hospitals emergency obstetric care. In the second tier, admit women with or without a referral for both there are general hospitals which provide the normal and caesarean delivery services and same services as primary hospitals, but have share similar characteristics with other hospitals over 50 beds, and are designed to provide a of their levels in the country. See Table 2 for pro- range of specialist services including gynaecology files of the study hospitals. and obstetrics, paediatrics, internal medicine, The intervention surgery, psychiatry and emergency services, and include diagnostic facilities and therapeutic The rationale for this intervention arises from the interventions. Specialised hospitals form the lack of (1) a stand-alone RMC promotion package third tier and serve as referral centres for general in Ethiopia and (2) evidence on the effectiveness hospitals. and implementation challenges of RMC interven- The study was conducted in three public hospi- tions in Ethiopia and globally. There were three tals (two general and one primary hospital) and components to the RMC intervention: a three- their corresponding programme administrative day offsite staff training on RMC; placement of units. The hospitals were selected based on the wall posters in labour wards; and onsite suppor- primary author’s familiarity with the settings tive supervision. The intervention focused on the and intention to have an appropriate mix of interpersonal aspect of care, including the Table 2. Profiles of study hospitals Characteristics Hospital I Hospital II Hospital III Geographical and population profile (2017) Location (urban/rural) Urban Semi-urban Semi-urban Catchment population 359,358 261,271 267,589 Expected pregnancies in the catchment 12,434 9,040 9,259 Number of public hospitals in the catchment (including 03 01 01 current one) Number of health centres in the catchment 05 09 11 Facility profile Total number of births attended in the last quarter of 2017 1081 433 713 Total number (%) of caesarean births in the last quarter of 164 (14.9) 62 (14.3) 138 (19.4) Upgraded from a lower-level facility (Yes/No) Yes Yes No Number of labour wards 02 01 01 Total number of beds in the labour ward 10 (5 in each) 05 05 Number of delivery rooms 01 01 01 Total number of birthing beds in the delivery room 04 04 3 Type of delivery room (Partitioned/Non-partitioned)* Non- Non- Non- partitioned partitioned partitioned Number of functional showers in the labour ward 0 02 01 Number of functional handwash basins in the labour ward 01 02 01 Designated waiting area for accompanying family members Yes Yes Yes (Yes/No) *Open plan with multiple beds per room with no curtains/partitions. 459 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 recommendation for the admission of birth com- Focus group discussions panions, but did not involve structural or hard- Participants of the FGDs were service providers ware components. Further detail about the who provide care during labour, childbirth, evaluation of the intervention from women’s and immediate postpartum periods in the and service providers’ perspectives is available in maternitycare unitofthe studyhospitals.The 36,37 other studies published elsewhere. pre-RMC intervention FGDs were conducted in Implementation of the whole set of components three public hospitals; two FGDs were conducted of the intervention lasted for three months. All in one of the hospitals, while one FGD was con- service providers who assist women in the study ducted in each of the other hospitals. A total of hospitals (n = 69) were invited to participate in 32 participants took part in the pre-RMC inter- the intervention. Eventually, 64 service providers vention FGDs (6–10 participants in each FGD); received all the intervention components includ- 24 of the participants were female, while the ing the training; five service providers did not remaining 8 were male (Table 4). A total of 21 attend the training for personal reasons. The par- participants took part in the post-RMC interven- ticipants comprised 51 midwives (79.7%), 4 gen- tion FGDs (6–8participantsin eachFGDs; 1 in eral practitioners (6.3%), 4 integrated emergency each intervention hospital) that were conducted surgical officers (6.3%), 3 nurses (4.7%), and 2 two months after the intervention; 15 of the health officers (3.1%); 44 (68.8%) were female participants were female, while the remaining and a similar percentage were aged between 22 6 were male. Participant selection for the pre- and 29 years. Table 3 shows details of the com- intervention FGDs was conducted based on the ponents and participants of the intervention. availability of service providers and depending The RMC intervention goes in line with the core on their duty assignment. The maternity care themes of the caring, respectful, and compassio- unit coordinators invited all service providers nate (CRC) health workforce initiative, one of the who were not on day-time duty and those who four transformation agendas of Ethiopia’s Health turned up were included. All participants (32) Sector Transformation Plan (2015–2020). A of the pre-RMC intervention FGDs received the 2019 government review indicated that lack of RMC training, making 50% of the RMC training ownership and engagement of stakeholders at participants. For the post-RMC intervention all levels, lack of system-wide implementation, FGDs, candidate participants (those who lack of finance, weak monitoring and evaluation attended the RMC training and who were not systems, lack of research and evidence in the on day-time duty) were invited to participate field, and resistance among providers were in an FGD (Table 4). The pre-intervention FGDs among the key challenges in implementing the were conducted to explore the knowledge of ser- initiative. While the CRC initiative is generic vice providers on quality maternity care, RMC, and designed for the entire health service in the and the mistreatment of women; health system country, it lacks depth and focus to address the challenges; service providers’ experience in the core themes of RMC. In contrast, the study inter- provision of RMC; the contributors to the mis- vention dealt with promoting all components of treatment of women in health facilities; de/ the RMC charter and involved the mechanisms motivators of RMC provision; and seek for their to track progress and take improvement actions. recommendations of what needs to be done to improve RMC. The post-intervention FGDs explored the challenges service providers experi- Sampling and recruitment enced during implementation of the RMC train- We conducted 7 focus group discussions (FGDs) ing and further actions required to promote with service providers (4 FGDs before the RMC RMC. intervention and 3 FGDs after the RMC interven- The preliminary analysis of the formative data tion) and 12 in-depth interviews (IDIs) with key set – 4 pre-intervention FGDs and 12 pre-interven- informants. As the IDIs aimed to explore the status tion IDIs – helped us to contextualise the RMC of respectful care in the hospitals and existing training, notably the addition of a consultative challenges to providing RMC from the perspectives discussion with training participants, hospital of key informants who hold a managerial position, administrators, and programme managers on all were conducted before the RMC intervention. the last day of the training sessions. 460 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Table 3. Description of the RMC intervention Component Description Participants Intervention period RMC training The RMC training manual 64 service providers at the First round: included contents on an overview participating hospitals who 25–27 April 2018 of maternal health in Ethiopia; assist women during Second round: 2–4 May 2018 human rights and law in the childbirth (in two rounds) context of reproductive health; RMC rights and standards; professional ethics; and continuous quality improvement. The manual was designed after a thorough review of RMC implementation programmes in Kenya, Tanzania, and Nigeria; and WHO’s recommendations of Intrapartum Care for Positive Childbirth Experience; and national guidelines and professional ethics codes. Wall posters Four wall posters All (64) training participants 25 April–4 May 2018 The universal rights of The wall posters were Posters were handed over to childbearing women prepared included in the RMC training the hospitals’ MCH by the White Ribbon Alliance manual and all participants coordinators at the end of (one poster) were briefed on these. the second round training Infographics taken from the session. intrapartum care for a positive childbirth experience guideline prepared by the WHO (three posters) Onsite Two rounds of post-training All (64) service providers who First round: June 2018 supportive quality improvement supportive attended the RMC training. Second round: July 2018 supervision supervision were conducted to (There were service providers appraise the action plan who attended both rounds of implementation, and to set the supervision.) actions for the next cycle with the long-term aim of developing a culture of continuous quality improvement actions. Guidance on a facility-led assessment of RMC using a structured checklist that was part of the RMC training manual. Guidance on action plan development to address actionable gaps identified by the assessment checklist. In-depth interviews programme levels. Key informants at the hospital All IDIs were conducted before the RMC interven- level were maternal and child health coordina- tion with key informants at hospital and tors, institutional quality focal persons, medical 461 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Table 4. Summary of participants and topic areas investigated during FGDs and IDIs No. of FGDs/ Category Facility IDIs Total no. of participants* Topic areas explored Pre- Hospital I 2 16 (14 midwives, 2 nurses) Features of quality maternity care; intervention twice and perception of Hospital II 1 8 (7 midwives, 1 integrated FGDs mistreatment; twice and perception emergency surgical officer) of respectful care; contributors to mistreatment; challenges Hospital III 1 8 (7 midwives, 1 health officer) experienced in labour wards; motivators and demotivators to provide respectful care; actions required to promote respectful care Post- Hospital I 1 7 (6 midwives, 1 nurse) Perceived behavioural influences of intervention the training; challenges encountered, Hospital II 1 8 (8 midwives) FGDs and new behaviours emerged in implementing the training; additional Hospital III 1 6 (5 midwives, 1 general actions required to implement the practitioner) training; partakers of RMC Pre- Hospital I 4 4 (MCH** coordinator, quality Features of quality maternity care; intervention focal person, medical director, twice and perception of IDIs and chief executive officer) mistreatment; twice and perception of respectful care; contributors to Hospital II 4 4 (MCH coordinator, quality mistreatment; perceived status of focal person, medical director, respectful care; respectful care and chief executive officer) initiatives; challenges in advancing respectful care Hospital III 3 3 (MCH coordinator, quality focal person, and medical director) Regional 1 1 (senior maternal health health expert) bureau *Most FGD participants were midwives because 80% of service providers who assist women during childbirth in the study hospitals were midwives. **MCH: Maternal and child health. directors, and chief executive directors of the Data collection three intervention hospitals. The programme Pre-intervention FGDs and IDIs were conducted level IDI was conducted with a senior maternal from March 2018 to April 2018, and post-interven- health expert at the SNNPR Health Bureau tion FGDs were conducted in July 2018. Initially, (Table 4). The key informants were selected aim- semi-structured interview guides were developed ing at obtaining rich information from both hospi- in English after a thorough literature review. The tal and programme levels that could enable us to key topic areas explored during the FGDs and meet the study objective. The IDIs explored the IDIs are presented in Table 4. The FGDs lasted constraints to the promotion of RMC from the per- 45 minutes to one hour while the IDIs lasted spectives of programme managers and adminis- 20–30 min. trators who look after the programming and The guides were then reviewed for content and operation of maternal health services at hospital, clarity by two of the co-authors. The primary zonal, and regional levels. author translated the final version interview 462 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 guides for both the FGDs and IDIs into Amharic Ethical considerations language and used these versions to collect data Ethical approval for this study was obtained from in Amharic. Data were collected and digitally the University of Melbourne (Australia) and the audio recorded by the primary author, who is SNNPR Health Bureau (Ethiopia). Participants familiar with the local context. Participants were were given a plain language statement about the provided with compensation for local study that they read before consenting to partici- transportation. pate; all participants gave written consent before participating in the study. Data analysis The primary author did the simultaneous trans- lation (from Amharic to English) and transcription Findings and interpretations of the audio recordings. The transcribed data were We identified seven health system factors influen- then imported into NVivo software (QSR Inter- cing the promotion of RMC belonging to the cat- national, Version 12 Plus) for analysis. Data from egories of system hardware (bed availability; the pre-and post-intervention FGDs and IDIs infrastructure and supplies; financing; and health were analysed concurrently. Data were coded workforce) and system software (staff motivation; inductively and deductively using standard quali- service providers’ mindset; and awareness of tative methodology, and analysed in two steps, RMC). These elements exhibited complex inter- first inductively to identify themes emerging actions with each other, amplifying the challenges from the transcripts and then deductively using of implementing RMC. Limited responsiveness the complex adaptive systems theory. Addition- within the maternity care system constrained ally, complexity theory helps to synthesise the implementation of the RMC recommendations. constraints to RMC through the lens of inherent In the following sections, we report on the system organisational complexities in hospitals; evidence interactions by identifying where complex adap- from such synthesis can later be translated to tive system processes were at play, which are tackle implementation problems. Coding of depicted in Figure 1. Consistent with complex sys- data was undertaken by the primary author tems, some of the themes have shared causal fac- after reading and rereading the transcripts to tors and intersect with each other. identify themes that impede RMC; the themes were then reviewed by one of the researchers Bed availability (AM). The agreed-upon themes were then grouped All study hospitals have only one labour ward and into either system hardware or system software one delivery ward (separate from the labour ward) categories, according to Elloker et al. In this con- where women stay together; there are four to six text, system hardware refers to supply, health hospital beds in each labour ward and three to workforce, facilities, and financing, whereas sys- four birthing beds in each delivery room (Table tem software refers to knowledge and mindset, 2). In response to the rising client flow, one of referral system, support and motivation, and ser- the hospitals had previously built a new maternal vice delivery guidelines. Following the thematic and child health unit which helped to separate analysis, we used complex adaptive system theory obstetrics and gynaecology wards while the as a framework to explore and map the complex remaining two have renovated their labour interactions within and between the system hard- wards to accommodate more beds. ware and system software elements. This approach of data- and theory-driven analysis is “We are restructuring the wards using partition suggested by scholars to improve rigour in the- boards to add two more beds. As a long-term sol- matic analysis. The primary author developed ution, we are constructing a new hospital building a causal loop model using Vensim software to that will take about two years to be available for visualise the interactions between different sys- service.” (Coordinator, Hospital I) tem elements in the maternity care system that Despite these facility-level remedies to increase affect the delivery of RMC. The developed model bed capacities, all study hospitals experienced was then reviewed by all authors. We used the patient numbers that exceeded bed capacity: consolidated criteria for reporting qualitative research to report important aspects of this “… the main challenge is the shortage of beds, study. especially during the night-time; there is a huge 463 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Figure 1. Causal loop diagram of factors influencing respectful maternity care in hospitals* Notes: “+” sign on the blue arrows indicates the causing variable increases the outcome variable. “−” sign on the blue arrows indi- cates the causing variable reduces the outcome variable. “R” in the red rotating arrows indicates the variables have a reinforcing effect on each other in the direction of the arrow. complaint from staff and the community in this bypass health centres, assuming that they will regard. Sometimes, it is the gatekeepers who tell receive better service in hospitals, an important women coming by ambulance to turn around and factor explaining the shortage of beds and over- look for other hospitals in the city.” (Coordinator, crowding in hospitals. Participants also said that Hospital I) many women are referred from lower-level facili- ties without any clinical indications requiring Although women can give birth in lower-level referral and could have given birth safely at pri- health facilities, participants reported that most mary level health services and that bypassing women who come to hospitals for childbirth these facilities increases pressure on the hospitals. 464 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 “More than half of the women who give birth in our women. As a result, service providers faced a hospital can give birth at health centre levels. dilemma of which aspect of RMC to prioritise – Women bypass these facilities, and there is also privacy or labour companionship. Eventually, an inappropriate referral of women from these labour companions were denied admission in facilities. Last month, 59 women who were referred labour wards, especially in two of the hospitals, from ‘health centre A’ gave birth in our hospital because of the privacy concerns. without any particular procedure for an assisted “Because we do not have adequate [privacy] delivery (vacuum or forceps). ” (Coordinator, Hospi- screens, we are asking all labour companions to tal III) go out of the ward whenever a woman is to have In response to the overcrowding, health workers an examination …” (Service provider, post-RMC are faced with the following choices to manage intervention FGD, Hospital III) excess client flow: admitting women who are in The interaction between the lack of privacy and labour to wait in corridors until someone gets dis- the admission of labour companions in labour charged, or referring women to other facilities, wards proved to be competing forces, a manifes- including those who have already been referred tation of non-linear inter-relationships. Service to them from other facilities. providers’ understanding of privacy seemed to extend only to the companions of other women Infrastructure and supplies in the ward, not to the other women (residing) In all hospitals, in addition to the overcrowding in the ward, who are also strangers. This implies described above, there were both space con- privacy is still lacking, although the degree may straints and supply shortages. The absence of priv- be less than when companions are in the room. acy screens was a key constraint to the provision of In a different context, there might be a positive respectful care, especially maintaining women’s relationship between the presence of labour com- privacy during vaginal examinations. In the two panions and RMC, but in a context in which avail- upgraded hospitals, there was only limited expan- able supplies, especially privacy screens, were sion of the labour wards, delivery rooms, and often lacking, the expected relationship is modi- waiting areas for families, meaning that the reno- fied and effectively reversed. In effect, this par- vations have not equipped the hospitals with ade- ticular hardware issue is among the key system quate space given the expansion of services. elements jeopardising RMC. Other supply issues identified were the short- “This hospital was a clinic 57 years ago; it was then age of bed linen; infection prevention supplies upgraded to a health centre and later to a primary including aprons, gloves, soap and chlorine sol- hospital and then general hospital without signifi- utions; blood packs; essential medicines including cant expansions. That is why the buildings/rooms ergometrine; and foetal monitoring equipment. are not conducive to provide services to the level Furthermore, lengthy procurement procedures that a general hospital should do.” (Manager, Hos- and the supply of low-quality medical equipment pital I) were additional challenges to the continuous Following the RMC training, all hospitals allowed availability of supplies: labour companions to accompany women in “… a respectful midwife cannot address all labour wards, which meant there were several requirements of respectful care alone. He/she companions in one labour ward. The willingness must be provided with required supplies …” (Coor- among staff indicates that there is a real opportu- dinator, Hospital II) nity to promote labour companionship in the long run. However, participants said that it was chal- In the case of acute stockouts of recurrent lenging to maintain women’s privacy during vagi- supplies, hospitals adapted to these situations by nal examinations because there are several commissioning special purchase of supplies “strangers” in the labour wards which are already using their internal revenue, asking for support considered small, given the number of beds they from non-governmental partner organisations, accommodate, as indicated in Table 2. Thus, and borrowing from nearby health facilities. To while the admission of labour companions likely initiate an independent purchase of missing benefited women during labour, it simultaneously supplies mentioned above, hospitals require an had an undesirable effect on the privacy of other 465 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 out-of-stock clearance from the Ethiopian entitled to get from hospitals.” (Coordinator, Hospi- Pharmaceutical Supply Agency. Once hospitals tal III) are granted permission, meeting the require- The fee-exemption was introduced first in health ments of government procurement guidelines centres and then in hospitals between 2005 and was reported to be very challenging. 2010. In principle, hospitals apply to the Ministry “We have allocated a budget for the purchase of of Health at the end of every quarter for reimbur- supplies. However, it is tough to get these in the sement for the costs incurred to deliver fee- market. How could I admit a woman for labour exempted services. While the fee-exemptions when I do not have a glove to use? A mother will were regarded as positive in promoting equity, get referred without her will and consent …” (Man- challenges arose to meet the expectations for ser- ager, Hospital I) vices. For example, delays in reimbursement were reported in all hospitals and contributed to supply Additionally, participants described several facility shortages because hospitals were not able to constraints including dysfunctional or complete accumulate funds that they could use for procure- absence of utilities like shower and sinks, shortage ment. We identified an emergent behaviour in of water supply, no waiting area for companions, response to the implementation gap of the fee- and poorly ventilated wards. These challenges exemption policy for maternal health services – were also the reason why service providers did requesting women to buy supplies: not allow women and their families to perform cultural ceremonies/practices that they would do “… now, we are in the second quarter of the cur- if the woman had birthed at home. Hospital rent budget year. However, we did not yet get reim- administrators have indicated that they have bud- bursed by the Ministry for our expenses of the get limitations for regular maintenance and reno- second quarter of the previous budget year. We vation works. Accordingly, the supply and facility are in a big challenge currently.” (Manager, Hospi- constraints in the hospitals were influenced by tal II) complex interactions between various agents such as leadership, governance, and financing, Insufficient and delayed release of budgeted which are complex systems themselves. funds were the two other key challenges affecting These supply, space, and facility constraints the management and delivery of childbirth ser- have direct (denying women the required level vices in the hospitals. The beginning of a fiscal of services and resulting in unnecessary referrals) year is the most challenging period when hospi- and indirect (damaging providers’ commitment tals encounter difficulties in paying compensation to provide care due to health and safety concerns) for services such as night and weekend duties, as negative effects on RMC. the new fiscal year’s budget is not usually released for use on time. Consequently, service providers wait for months to get paid for their weekend Healthcare financing and night duties, and this has resulted in demoti- vation of service providers and a negative relation- All hospitals were implementing a financing rec- ship between service providers and ommendation set forward by the Ethiopian gov- administrators. ernment to make antenatal, delivery, and Financial bottlenecks also resulted in the postnatal care services available free of charge assignment of a substandard number of midwives in public health facilities although there were for night and weekend duties to minimise some inconsistencies before the CRC initiative. expenses. As such, the assigned service providers As part of the government’s initiative to promote bear a higher workload than they are supposed CRC, the hospitals waived the fee for investigations to; this often leaves them frustrated and even- conducted during pregnancy and childbirth, tually results in the mistreatment of women. including obstetric ultrasound. “… in some hospitals and most health centres, an “Investigations, including ultrasonography, for adequate number of midwives are not assigned women are provided free of charge with a special for night duties; this practice is totally against the consideration not only to make them happy and standard, and it happens because health facilities encourage them to give birth in health facilities do not want to pay for night duty. There are but also to provide the services that they are 466 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 occasions five or more labouring women come in a Hospital administrators reported that they use the single night, and the workload makes us ‘health national pay scale, and they do not have the auth- providers’ to behave disrespectfully.” (Service provi- ority to adjust salaries and other payments how- der, pre-RMC intervention FGD, Hospital I) ever they share providers’ complaints. These complex interactions between different “Because what is being paid here is low, service pro- agents in the financing system left hospitals in viders look for part-time jobs elsewhere. That, in financial bottlenecks which in turn added to the turn, compromises the quality of service in our hos- complexity in the maternity care system (affecting pital as service providers get fatigued … I know this the availability of supplies, deployment of ade- is a national problem and cannot help it …” (Coor- quate staff, timely payment of remuneration, dinator, Hospital I) etc.), making it difficult to practice RMC. The Midwives reported that there is an unfair gap of delay in providers’ night and weekend duty pay- risk allowance among different professions; mid- ments made providers feel disrespected, further wives report receiving 470 birr (∼17 USD) per compounding the complexity of RMC delivery. month while health officers and emergency nurses receive a higher risk allowance, 1250 birr Staff motivation (∼46 USD) and 1200 birr (∼44 USD), respectively. As part of the CRC initiative, all hospitals have Managers have also expressed the gap as inap- introduced staff appraisal and recognition cer- propriate and creating dismay among midwives. emonies which occur every six months to give Midwives claimed that they are exposed to a awards to the best performing staff from each higher level of professional risk, such as infec- unit of the hospitals, including maternity units. tions, compared to health officers and emergency The coordinator of one of the hospitals reported nurses. Because of these dissatisfactions, the lack that they also have a fortnightly coffee ceremony of career opportunities, and the relatively better in which women and their families are involved pay that other non-health professional graduates and best practices and gaps identified are dis- (such as accountants) of the same years of employ- cussed. This recognition was important to improve ment receive, participants said that fellow mid- staff morale. wives are leaving the profession. “… there are CRC focal persons in each unit who “Practicing midwifery is difficult in Ethiopian facili- appraise respectful care, deal with breach of pro- ties; as a midwife, you are supposed to work for 24 fessional ethics, and hold group meetings with hours if you have night duty, the workload is excep- their team. The best performer professional is tionally high, you take care of several women at a selected every six months from each unit, and a cer- time. Disproportionately, your salary is very low, tificate of appreciation is awarded to motivate as is your risk payment.” (Service provider, pre- them.” (Coordinator, Hospital I) RMC intervention FGD, Hospital II) However, there were simultaneously weak staff The interaction between high workload and attri- incentives and a lack of motivation schemes in tion of midwives exhibited a positive feedback hospitals, which had a negative effect on RMC by loop: the more midwives resign, the higher the damaging providers’ enthusiasm to provide workload becomes, which in turn leads the respectful care. These included: low salaries; risk remaining midwives to resign. This emergence of allowance gaps among professions; lack of sup- behaviour (resignation) among midwives due to port and recognition by managers; lack of career the longstanding problem of staff motivation, opportunities; undefined career path (especially including a lack of career path, further makes for midwives and integrated emergency surgical the delivery of RMC complex. Given the shortage officers); low and delayed remuneration for of midwives in the country, such preventable attri- night and weekend duties; and lack of a positive tion would again add to the complexity of health work environment. workforce availability and quality and is a barrier “Sometimes, you keep on doing and discharging to promoting RMC. your responsibilities appropriately, but no one Health workforce from the senior managers comes to you and sees what you do and gives you recognition.” (Service Both program coordinators and administrators provider, post-RMC intervention FGD, Hospital I) emphasised that the shortage of staff, especially 467 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 midwives and obstetrician-gynaecologists, needs were mistreating women intentionally and to be resolved if respectful care is to improve. Hos- unintentionally. pitals recruit obstetrician-gynaecologists on a “Junior professionals adopt behaviour of their short-term and often expensive contract basis to seniors. The trend so far was distancing and hierar- fill the acute shortages of these specialists, and chy between different professionals and between that is draining their revenues. professionals and patients; that finally leads to A manager of one of the hospitals reported that the designation of providers as “bosses” who order obstetrician-gynaecologists do not want to work patients what to do.” (Coordinator, Hospital III ) on a permanent basis in order to take advantage of the higher salary, sometimes more than three “… there is a wrong tradition of regarding health times the regular salary that hospitals offer on a professionals as kings among service users; ‘no contract basis. The more the hospitals pay for con- one can talk to them’ type of thought. That resulted tract-based recruitment, the less likely specialists in some providers feeling proud of their professional are to take full-time positions. status and undermining others …” (Manager, Hos- The shortage of professionals has created an pital II) increased workload, fatigue and negligence, The post-intervention FGDs revealed that some unnecessary referrals, and failure to respond to providers have reservations about the feasibility women’s preference of service providers. Dissatis- of fully respecting the universal rights childbear- faction with the work climate and dysfunctional ing women should have in health facilities. Provi- professional hierarchy, in addition to the low ders reported that the rights of women could not pay, were also identified as the key reasons for be entertained given the existing multidimen- the high turnover of service providers in the sional constraints reported in this study. Addition- hospitals. ally, providers required their rights also be “… It is the standard to have two providers for a defined and guaranteed. labouring woman; one for the mother and one for “… in 99% of the cases, health facility management the newborn. However, we do not practice that attend only to the rights of clients; they do not always since there is a shortage of workforce … emphasise the rights of professionals …” (Service this makes providers nervous at the end.” (Coordi- provider, pre-RMC intervention FGD, Hospital I) nator, Hospital III) After the RMC training, some providers opposed the distribution of a pamphlet on The Universal Service providers’ mindset Rights of Childbearing Women (Amharic version) that had been endorsed by the Ministry of Health. Service providers who participated in the interven- Eventually, none of these pamphlets were distrib- tion showed a willingness to implement practices uted. Participants said that women and their com- to support RMC. These included allowing support panions demand to exercise the rights included in by labour companions, allowing women to birth the pamphlet and that providers are not able to in their preferred position, and seeking women’s address these due to system hardware constraints consent before procedures, and reflected a level despite most rights on the declaration being of agency amongst the staff and a commitment related to interpersonal care. to quality improvement initiatives. “… we used to provide care with force if women “… for example, I had a long night assisting refused to have a procedure or an examination. women, but I am not paid fairly. Is it fair to accuse After the training, there is no such practice; we pro- me of violating women’s rights? I do not think … a vide services with consent and respect.” (Service lot must be done from top to bottom in responding provider, post-RMC intervention FGD, Hospital II) to providers right before trying to maintain women’s right.” (Service provider, post-RMC inter- Yet health workers also faced entrenched inter- vention FGD, Hospital III) personal hierarchies of care that constrained Even after receiving the RMC training, some ser- RMC. Because of an intergenerational trend of vice providers continued to express the idea that hierarchical patient-provider and provider-provi- it is acceptable to disrespect women when provi- der relationships and the lack of awareness of ders are not also respected. the constituents of RMC, participants said they 468 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Awareness of RMC the lessons learned through its implementation, including the enablers of RMC (mixed-methods Before the RMC training, RMC was a new terminol- study among service providers who participated ogy to participants of the FGDs and IDIs; similar in the intervention). The survey of women were “mistreatment” and “disrespect and revealed that the number of mistreatment com- abuse”. Participants had an awareness of what ponents women experienced during childbirth in respectful care means, mostly in its interpersonal the study hospitals was reduced by 18% after the aspect, while they lacked awareness of its systemic RMC intervention. The mixed-methods study aspects. As supported by participants of the post- revealed that service providers’ awareness of the intervention FGDs, short-term RMC trainings like rights of childbearing women, perceptions and the one implemented in this study play a key attitudes about RMC, and motivation to provide role in improving service providers’ awareness of respectful care improved after the RMC RMC and the rights of childbearing women in intervention. health care settings. To our knowledge, this is the first study to “I am now aware that I may disrespect women in explore the status of RMC through the theoretical various ways. On the other hand, I have also under- lens of complex adaptive systems, which allowed stood that I can serve women very nicely and make us to focus both on structures and functions (pro- them satisfied with little efforts. I have also learned cesses) of the maternity care system and the inter- what makes women displeased.” (Service provider, play between these. We have synthesised the post-RMC intervention FGD, Hospital II) findings of this study using a causal loop diagram that shows the complex relationships between Participants recommended that support staff who different system elements in the RMC system have a direct or indirect role in maternity care, (Figure 1). including the reception at the hospital entrance The interaction between system hardware and gate, should also receive the training, with the jus- software constraints in maternity settings was com- tification that RMC cannot only be achieved by the plex and warrants a systems approach to improve care in maternity wards. A programme coordina- RMC. A system constraint can affect both clinical tor at the regional level outlined that there is a and non-clinical maternity care components at gap in knowledge of RMC because the existing ser- the same time or may have spill-over from one of vice delivery guidelines lack content on RMC. these components to another due to the existence of interactions between the components. Simi- Discussion larly, an intervention component that aims at Service providers’ lack of knowledge of RMC and improving a system component may have a posi- an unconscious normalisation of disrespectful tive or negative consequence on other com- care highlights the need for tailored RMC edu- ponents. For example, weak implementation of cation. Nonetheless, it is important to emphasise the fee exemption for maternity care services the non-behavioural challenges that also need to resulted in a lack of revenue and supply shortages be addressed to ensure that knowledge is trans- in the hospitals; in response, women were asked to lated into practice. We conducted this study to buy supplies in direct contradiction to the policy. outline the system constraints to the promotion Not only is this disrespectful, but it may also offset of RMC in public hospitals from the perspectives the intended aim of the fee removal, which is to 46,47 of service providers and managers. The pre- and improve service utilisation. post-RMC intervention qualitative enquiries bene- System hardware and software constraints chal- fited this study in identifying the complex inter- lenged the implementation of RMC recommen- actions between various system elements in the dations. For example, financial limitations in the absence of and with the intervention. Notably, study hospitals led to a complex relationship the post-RMC intervention FGDs helped to demon- affecting recruitment and motivation of staff, strate how the interaction between various system availability of supplies, and maintenance of facili- constraints could mark the implementation of ties. A study from Kenya also demonstrated that RMC recommendations. financial limitations negatively impacted service In two other studies, we have reported on the providers’ and hospital administrators’ motivation evaluation of the RMC intervention (survey of to implement hospital initiatives. According to women before and after the intervention) and Clark, such complex problems necessitate 469 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 complex interventions (interventions that encom- facilities and to build communities’ confidence pass different parts such as financing, supply, in these facilities. Without these actions, improv- workforce, infrastructure, and others) but cannot ing RMC only in hospitals means more women be solved by behavioural interventions alone. keep on bypassing primary facilities because of Therefore, as outlined by the WHO, implementing preferences for hospital-level care in the commu- context-based complex interventions to improve nity, generating factors which impede improve- the quality of services is instrumental in promot- ment of quality of care in hospitals. ing RMC. While it is appropriate that regulatory and Evidence reviews report that having a labour financial control mechanisms aim at ensuring gov- companion during labour and childbirth helps ernance and reducing corruption in the health women to have a positive childbirth experi- system, they may also result in lengthy bureau- 50,51 ence. In this study, service providers encoun- cratic processes if poorly designed and/or tered the problem of sustaining practices of implemented, which can lead to disrespectful 35,58 admitting labour companions and allowing cul- behaviours among service providers. Nothing tural practices in labour wards, due to space and justifies disrespectful or abusive treatment of privacy constraints, and because an admission of women, but these working conditions make it companions inadvertently fed back negatively on more likely. A review by Reader and Gillespie the privacy of women. Such constraints are also reported that such institutional causes result in critical challenges in promoting the culture of normalisation of patient neglect and abuse labour companionship in health facilities glob- among providers and should therefore be ally. These constraints also indicate that addressed from both behavioural and organis- women’s privacy is already in jeopardy in the ational interventions. absence of adequate infrastructure. Addressing A noteworthy finding of this study is the impor- these barriers plays a crucial role in promoting tance of involving health managers in any health RMC and quality of care and contributes to the worker behaviour intervention. Service providers 53,54 improved uptake of maternity care services. reported being demotivated as they were improv- Furthermore, taking a contextualised and proac- ing services as per the RMC training guideline. Yet, tive approach to planning for health systems infra- no one from the facility management recognised structure improvement is required to improve the these efforts – a missed opportunity to keep up quality of care, mitigate the consequential and the enthusiasm for change. A study from Benin unintended impacts of innovations, and respond reported that management support and recog- to the evolving needs in LMICs, including nition of midwives and other staff was vital in sus- 3,49 Ethiopia. taining positive changes gained from a humanised Women bypass lower-level health facilities, as childbirth intervention. indicated in this study, due to lack of confidence Strengths and limitations in lower facility providers, perceived low-quality of service, and fear of referral processes in case Exploring service providers’ perspectives of apply- of a birth complication in lower-level facilities. ing new knowledge into practice is of paramount When this is coupled with the lack of bed capacity importance to plan for future interventions that in hospitals, it predisposes women to mistreat- can be applied in the real world. In this regard, ment by denying them the timely and quality the conduct of FGDs both before and after the care they deserve. It also results in a second refer- RMC intervention is the main strength of this ral and hospitals have to deal with client overflow. study as it profoundly helped us to have a richer A study conducted in three regions in Ethiopia understanding of how multiple interactions reported that 86.4% of patients visited hospitals between various system constraints could offset without referral, and bypassing was common the implementation of RMC recommendations among maternal and child health care seekers. and other similar quality improvement initiatives Similarly, a Tanzanian study also found that 44% in maternity settings. Additionally, the use of com- of women bypassed primary health facilities for plexity theory in the data analysis surpassed the childbirth mainly due to concern about the qual- depth of evidence that would be obtained by ity of care at health centres. It is, therefore, the traditional approaches of exploring single essential to improve the quality of maternity cause and effect relationships; it brought the care services in lower-level primary health wider picture of how various entities interact 470 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 with each other and directly or indirectly affect implementation of RMC from a health system RMC in the real-world setting. However, this strengthening viewpoint. We also recommend future study only reflects scenarios at primary and gen- implementation research in the field of RMC to eral hospitals and may, therefore, lack the bridge the discourse between theory and practice breadth to cover system constraints in referral in the local context. Finally, we believe that the find- and teaching hospitals and health centres in ings of this study inform policies and strategies to pro- Ethiopia. Additionally, since the post-intervention mote RMC in Ethiopia and other LMICs. FGDs were conducted two months following the intervention, our study is unable to explore how Acknowledgements systems adapted further after that point. In the The intervention part of this study was financially sup- current study, complexity theory was applied ported by the Institute for Healthcare Improvement post hoc for data analysis but did not guide the Ethiopia country office. The authors are indebted to development of data collection tools; this might the Federal Ministry of Health, the SNNPR Health have limited the completeness of the data col- Bureau, the Institute for Healthcare Improvement, lected and the opportunity to explore alternative the study hospitals, and Hawassa University College frames of analysis. Furthermore, participants of of Medicine and Health Sciences for their technical the post-intervention FGDs might have reported support during the conduct of this study. The authors their experiences of the RMC training in a way would also like to thank participants of the study for that would please the investigator who moderated their willingness to take part in this study. the FGDs, from social desirability bias. Funding The intervention part of this study was financially Conclusions supported by the Institute for Healthcare Improve- This study identified complex health system con- ment Ethiopia country office. straints that hinder the promotion of RMC in hospi- tals. Although quality of maternity care embodies ORCID both clinical and interpersonal aspects of care, this study highlights that interventions aimed at improv- Anteneh Asefa http://orcid.org/0000-0003-4470- ing only interpersonal or behavioural components 1848 fall short of mitigating the mistreatment of women Barbara Mcpake http://orcid.org/0000-0002- unless they also address the system-wide constraints. 9904-1077 As indicated in the study, there is scope for real Meghan A. 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Implementation research Health. 2014;11(1):71. in health: a practical guide. Alliance for health policy 48. Barasa EW, Molyneux S, English M, et al. Hospitals as and systems research. Geneva: World Health complex adaptive systems: a case study of factors Organization; 2013. 473 A Asefa et al. Sexual and Reproductive Health Matters 2020;28(1):456–474 Résumé Resumen Les données sur les difficultés rencontrées par le En Etiopía y mundialmente existe evidencia limit- système de santé pour promouvoir des soins de ada de los retos que enfrenta el sistema de salud maternité respectueux sont restreintes en Éthio- para promover atención respetuosa de la materni- pie et dans le monde. Cette étude a enquêté sur dad (ARM). Este estudio investigó las limitaciones les obstacles du système de santé qui contrarient del sistema de salud con relación a la ARM en des soins de maternité respectueux dans trois tres hospitales de Etiopía meridional. Realizamos hôpitaux du sud de l’Éthiopie. Nous avons mené un estudio cualitativo (siete discusiones en grupos une étude qualitative (sept discussions par groupe focales con prestadores de servicios de ARM y 12 d’intérêt avec des prestataires de soins et 12 entre- entrevistas a profundidad con personas focales y tiens approfondis avec des agents de liaison et des administradores) antes y después de la ejecución gestionnaires) avant et après la mise en œuvre de la intervención de ARM. Posicionamos los servi- d’une intervention de soins de maternité respec- cios de atención durante el parto dentro del sis- tueux. Nous avons positionné les services d’obsté- tema de salud y aplicamos la teoría del sistema trique dans le système de santé et appliqué une adaptativo complejo para analizar las oportuni- théorie de systèmes complexes adaptatifs pour dades y limitaciones para promover ARM. Se iden- analyser les possibilités et les limitations de la tificaron los factores de “hardware” y “software” promotion de soins de maternité respectueux. del sistema que influyen en la promoción de Des facteurs aussi bien matériels qu’immatériels ARM, y su interacción era compleja. Los factores influençant la promotion de soins de maternité de “hardware” eran: disponibilidad de camas, respectueux ont été identifiés et leur interaction infraestructura y suministros, financiamiento y était complexe. Les facteurs «matériels» compre- fuerza laboral de salud. Los factores de “software” naient la disponibilité de lits, les infrastructures abarcaban la mentalidad de los prestadores de et les fournitures, le financement et le personnel servicios, la motivación del personal y la concien- de santé. Les facteurs «immatériels» englobaient cia de ARM. Un ejemplo de las interacciones entre l’état d’esprit des prestataires de services, la estos factores era el incumplimiento de privacidad motivation du personnel et la connaissance des de las mujeres al admitir acompañantes del parto soins de maternité respectueux. Parmi les inter- en las salas de parto. El reembolso retrasado actions entre ces facteurs figuraient des violations después de la introducción de exención de tarifas de l’intimité des femmes lors de l’admission d’ac- por servicios de atención de la maternidad causó compagnants dans les salles d’accouchement. Les agotamiento de ingresos, escasez de suministros y délais dans les remboursements après l’introduc- comportamiento irrespetuoso entre prestadores tion de l’exonération des frais pour les services de servicios. Otras limitaciones financieras, entre de maternité ont provoqué une baisse des reve- ellas la insuficiente y retrasada liberación de fon- nus, des pénuries de fournitures et, en finde dos, también propiciaron complejas interacciones compte, un comportement irrespectueux des pre- con la motivación del personal y la disponibilidad stataires. D’autres obstacles financiers, notam- de fuerza laboral y suministros, lo cual produjo ment le décaissement tardif de fonds incumplimiento de la orientación sobre ARM. insuffisants, ont aussi provoqué des interactions Las intervenciones destinadas a mejorar solo los complexes avec la motivation du personnel et la componentes conductuales no llegan a mitigar disponibilité du personnel de santé et des fourni- el maltrato de las mujeres. Para abordar las com- tures, ce qui a abouti à une piètre observance des plejas interacciones que limitan la ARM, es nece- conseils sur des soins de maternité respectueux. sario ejecutar intervenciones en todo el sistema. Les interventions visant à améliorer uniquement les composantes comportementales ne suffisent pas pour atténuer les mauvais traitements subis par les femmes. Des mesures englobant l’ensem- ble du système sont nécessaires pour s’attaquer aux interactions complexes qui limitent les soins de maternité respectueux.

Journal

Sexual and Reproductive Health MattersTaylor & Francis

Published: Jan 1, 2020

Keywords: respectful maternity care; health system; complex adaptive system; system hardware; system software

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