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, non-confidential care, abandonment or denial of care, detention, and 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 collaborated 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):

  • determined the manifestations, definitions of types, and prevalence of D&A in childbirth;
  • developed and validated tools for assessing D&A;
  • identified and explored the potential drivers of D&A;
  • designed, implemented, monitored, and evaluated the impact of a constellation of interventions at the policy, health system, and community level to reduce D&A; and
  • documented and assessed the dynamics of the package of 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 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 designed and implemented effective, acceptable, and sustainable interventions that can be scaled up and adapted to other settings.

At the policy level, the research team worked 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 informed the legislation.

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

The Impact

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.

Internationally, the Council’s evidence, analysis, and convenings made a significant contribution to the development of the WHO’s statement on the Prevention and Elimination of Disrespect and Abuse During Childbirth, which was released at the 2014 UN General Assembly. The WHO statement calls for every woman to have the right to the highest attainable standard of health, including the right to dignified, respectful care during pregnancy and childbirth.

The WHO statement illustrates a commitment to promoting the rights of women and to promoting access to safe, timely, respectful care during childbirth. It calls for greater co-operation among governments, healthcare providers, managers, professional associations, researchers, women’s advocates, international organizations and women themselves to end disrespect and abuse during facility-based childbirth.

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