Heshima: Promoting Dignified and Respectful Care During Childbirth

The Heshima project is investigating the causes of disrespectful and abusive care during childbirth in Kenyan health facilities and developing interventions to reduce this problem.

The Issue

Many women face barriers to delivering their babies in health facilities, not least of which is disrespectful and abusive care during childbirth, including medical procedures performed without a woman’s consent, discrimination, abandonment, detention or denial of care, non-confidential care, and/or physical and verbal abuse. These practices violate a woman’s human rights and may discourage her from having an attended delivery in a facility, thus putting her and her newborn at risk.

While disrespect and abuse (D&A) appear to be widespread in both low- and high-income countries, its prevalence and contributing factors are not well documented, making it difficult to design and implement appropriate and effective interventions for ending these rights abuses.

The Population Council (through the USAID-supported Translating Research into Action Project) and the Ministry of Health in Kenya are collaborating with the Federation of Women Lawyers (FIDAKenya) and the National Nurses Association of Kenya-Midwives’ Chapter (NNAK-MC) to examine the extent and causes of D&A in Kenya and design and implement interventions to reduce the abuse. Specifically, the Heshima project (Heshima means "dignified" in Kiswahili) aims to:

  • determine the manifestations, types, and prevalence of D&A in childbirth;
  • develop and validate tools for assessing D&A;
  • identify and explore the potential causes of D&A;
  • design, implement, monitor, and evaluate the impact of one or more interventions to reduce D&A; and
  • document and assess the dynamics of implementing interventions to reduce D&A and generate lessons for scaling up.

The Progress

Using a combination of focus-group discussions, in-depth interviews, client exit surveys, health facility assessments, and observations with women and health providers, researchers have documented the prevalence of D&A, identified the main causes, and implemented interventions at the policy, facility, and community levels. By engaging stakeholders at all three levels, the Council and its partners expect to design and implement effective, acceptable, and sustainable interventions that can be scaled up and adapted to other settings.

At the policy level, the research team is working with a national technical working group of Kenyan policymakers to draft and pass a maternal health bill to reduce or eliminate D&A during childbirth; findings from the study are informing the pending legislation.

At the facility level, researchers have adapted a values clarification and attitude transformation training—originally developed by Ipas—to conduct trainings and counseling sessions with health facility nurses to help them cope with the stress of working in under-resourced facilities.

At the community level, the Population Council and partners have held community dialogues and are training community members on their rights to quality and respectful health care, effectively raising awareness of D&A. The team is also training community members to act as mediators between health facilities and women who have suffered D&A.

The Impact

To date, the Heshima project has received notable attention, including significant press coverage, both within and outside of Kenya. The research team has held meetings to validate its findings and design potential interventions, and has presented preliminary results at a number of international forums.

The team has raised awareness of D&A and health rights among the communities in which they are working and has seen greater cooperation in health facilities. The Council-developed training manual for values clarification and attitude transformation has had a significant impact at the facility level, and preliminary findings from the study have resulted in revisions to nursing guidelines and to the latest maternal and newborn health guidelines from the Kenyan Ministry of Health.

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