What are respectful services? Women and healthcare providers weigh in.

By Dorothy Balaba, Country Representative, PSI Ethiopia; Yvonne Mugerwa, Project Director, PSI; Brett Keller, Sr. Research Advisor, PSI; Okello Daniel Ayen, Kampala Capital City Authority; Henry Kaula, Implementation Lead, PSI; Andrew Magunda, Executive Director, Careerpath International; Peter Waiswa, Makerere University, Kampala, Uganda; Sam Ononge, Makerere University, Kampala, Uganda; Erica Felker-Kantor, Sr. Research Advisor, PSI

Women and Healthcare Providers Offer Their Perspectives on Respectful Maternal and Newborn Care Services in Kampala Slums

28-year-old Sara* lives in the urban slums of Kampala. She has two children and is currently pregnant with her third. To earn a living, she does menial work for other families. Her husband is unemployed and spends his days looking for informal work. And yet, with a new baby on the way, Sara knows she needs the resources to safely bring her newborn into the world. 

Almost 10 years prior, Sara remembers giving birth to her first child in a public health facility in her community where she had to pay bribes to the providers to access care and where the healthcare workers disrespected and yelled at her.  

Figure 1. A Kampala Slum where the study occurred.

For child number two, Sara wanted to deliver in a private health facility. But the cost was too high and so she chose to give birth in a different public health facility instead hoping it wouldn’t be as traumatic as her last experience. 

And it wasn’t terrible per se, Sara recalls.  Yes, the delivery experience was better than the first. But Sara was responsible for providing the birthing kits, gloves, sheets, and other materials for her own birth due to the facility’s shortage of medication and supplies.  

Sara’s experience with maternal healthcare in her community is not unique. While healthcare is geographically accessible in Kampala slums, the high cost and varied quality of services prevents women from utilizing services and receiving appropriate care.  

Insights

Maternal and neonatal health outcomes for the urban poor are often worse than in rural areas. According to the 2019/20 annual maternal and perinatal death review surveillance and response report, the Kampala institutional maternal mortality ratio was 207 per 100000 live births which was more than twice the national institutional maternal mortality ratio of 100 per 100000 live births. In Kampala’s slums, the estimated stillbirth rate is 43/1000 live births, which is more than double the rate of stillbirths in rural areas of the country. This suggests that despite the availability of maternal and newborn healthcare (MNH) services, urban poor women are not utilizing services or are not receiving quality care.  

Since the publication of a blog on the link between respectful maternity care and maternal health outcomes in 2019, the MaNe project conducted qualitative formative research to understand women’s and health providers’ experience and perspectives in two Kampala slums – Rubaga and Makindye.  

Findings showed that:

  • Women received poor quality of interpersonal care including disrespectful, abusive, and negligent treatment by health workers, as well as bad attitude from the providers.  
  • Health providers exploited the “out- of- stock” scenarios to demand under-the-table payments (bribes) from clients (mothers and their caretakers/spouses).  
  • Inadequate essential equipment and overcrowded public facilities led to frustration for both providers and clients.  

We’re Responding

The MaNe project worked alongside with Kampala Capital City Authority (KCCA) leadership to conduct four community-provider dialogues between clients and providers. Over 113 clients and 20 providers from four public health facilities in Kampala attended the dialogues. The dialogues were held outside the health facilities and attended by clients including mothers who had used services of the facilities, caregivers of mothers and newborns, those that were planning to use the facilities and health facility staff. Users of the facilities highlighted rudeness of the service providers and under-table payments (bribery) for a midwife’s service which is supposed to be free.  

To reduce overcrowding at public facilities, MaNe and KCCA are working to accredit private facilities to provide quality MNH services and negotiating with the proprietors of these facilities to lower the prices of services to an affordable level affordable for the urban poor. The private facilities were also linked to the Kampala ambulance system. In case of an emergency that requires transportation to the higher-level facilities, this is facilitated with no costs to the client or the private facility.  

The Outcome

  1. Service-providers pledged to improve MNH services and address the issues raised by the clients. KCCA authorities assured their commitment to accountability, by providing telephone contacts through which communities could report cases of disrespectful care at facilities. Community members requested more of these dialogues going forward.  
  2. Each KCCA public facility convened meetings to reflect on and address client concerns raised in the dialogues. The meetings raised a need for increased human resource to handle facility caseloads. Training and mentorship on respectful maternal and newborn care were held at the facilities.  
  3. Video/audio recordings were aired by local television and radio programs to increase clients’ awareness of their rights.  
  4. Provider attitude and quality of care improved following the dialogues. One client, who experienced services at the facility before and after the dialogue over the course of the same pregnancy highlighted having a better experience after the dialogues. 

Way Forward

  1. At the national level, clear policies and guidelines on reproductive health and rights must be in place but based on ratified international conventions and should provide practicable systems for legal redress.  
  2. At the facility level, have the critical health systems functional, including counseling support for providers, quality improvement to strengthen evidence-based facility level interventions, establishing accessible community-health facility linkages like maternity unit open days for pregnant women and caretakers, and safe mechanisms for reporting and addressing disrespect and abuse.  
  3. At community level, community sensitization on the rights of childbearing women and opportunities for continuous mediation/alternative dispute resolution must be put in place before the “fear of facility” is overcome.  

Dr. Frank Kaharuza, the Team Lead, Family Health at USAID Uganda, denotes the importance of stakeholder engagement and involvement.  

There is need to ensure all key stakeholders understand the work, are part and parcel of the solutions generation process and are conjointly participating in the decision-making process to drive programs forward,” he notes. 

The MaNe project’s work on community dialogue is one step in advancing respectful maternity care. Its implementation process has demonstrated that interaction between the frontline health staff and consumers can generate changes in the health system to meet the needs of women and families in urban poor areas. 

In support of Uganda’s continued efforts to improve maternal and newborn outcomes, Population Services International (PSI) Uganda and Kampala City Council Authority (KCCA) through the three-year Kampala Slum Maternal Newborn Project (MaNe) project, tested innovative approaches which addressed the demand and supply side barriers affecting care seeking, effective referral and provision of quality care for maternal and newborn health (MNH) in urban slums. The PSI and KCCA managed MaNe project, was supported by funding from the United States Agency for International Development (USAID). 

*name changed to protect privacy

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