Our results found that an RMC-focused intervention involving self-reflection which was embedded into a district-wide QI approach led to significant improvement in the two measures of RMC. These changes were sustained for 13 months after the conclusion of the collaborative support in December 2017. Qualitative feedback from participants indicated appropriateness of the approach, as it helped HCPs evaluate their care provision critically from their clients’ perspective. The QI initiative helped providers address some of the system related issues that contributed to D&A.
This study adds to the limited existing literature on successful strategies to improve RMC in Sub-Saharan Africa. As the intervention districts were distributed over the three agrarian regions of Ethiopia, the findings may be generalizable to other agrarian contexts.
Health care providers indicated that the testimonial videos were emotionally compelling and enabled them to understand the impact of substandard RMC practices. This finding is consistent with other studies that showed change in attitudes are best learned when applied to scenarios that replicate real life (31).
Birth companions provide emotional, psychological and social support. Recent studies have shown that the presence of a birth companion is associated with improved outcome both for the mother and the baby, including increased spontaneous vaginal delivery, shortened labor time and higher Apgar scores (19). The failure to allow a family companion during institutional childbirth is one of the deterrents to utilization of maternity care services in Ethiopia and other low- and middle-income countries (4). Despite previous concerns about hygiene, providers who had received the RMC training specifically recognized the importance of encouraging family support and companionship.
Lower results were seen in both privacy and birth companion data in Oromia from October to December 2017. This may have been due to civil unrest that took place during this time, which affected the short-term effect in the regression analysis. In SNNP, long-term effect may have been affected by the lack of the safe childbirth checklist. In cases in which the data is not recorded, it is assumed that services are not offered.
Previous studies that have evaluated RMC-related interventions have shown the importance of a multifaceted approach, including training on RMC and addressing barriers of RMC (14,28,32). Studies conducted in neighboring countries such as Tanzania and Kenya, using a pre and post comparative evaluation study, showed reduction in D&A ranging from 7 to 66% (14,32). Because we used available programmatic data, we were not able to show a specific reduction in D&A. However, our analysis shows significant improvement in births with privacy and companion following the RMC training.
Our study has some important limitations. As our analysis is based on available programmatic data, the study was not able to evaluate the status of RMC using all the seven Bowser and Hill’s categories of D&A, which may require interviewing clients and observing their interactions with providers. However, the RMC training module addressed all the seven D&A categories. In this study, we focused on two of the categories: ensuring privacy (non-confidential care) and allowing family companionship (non-consented care). These were shown to be the main grievances by mothers in Ethiopian settings (13,24,33–35).
We may have also underestimated the impact of the training, as there were many change ideas tested to improve the general experience of care along the MNH spectrum as described in Table 5. In addition, as data were collected from the medical record safe childbirth checklist, its unavailability in some of the health facilities led to lower coverage even when services are offered, again contributing to underestimation of the impact. Finally, without a comparison district, it is possible that the results were related to other factors, including the national initiative on CRC. Attributing results to just the RMC approach is difficult as integration within the QI initiative likely had a synergistic effect.
In conclusion, this study suggests that integrating RMC training into a QI collaborative is effective in improving RMC. Use of testimonial videos are especially helpful as they appeal to the heart and remind HCPs of their moral obligation to treat mothers with dignity. Embedding this intervention within an ongoing QI effort enabled HCPs to look deeper into the care process and to reform it in ways that are genuinely family and women-centered. In relation to this, engagement of the facilities’ and districts’ health leaders was crucial in allocating resources to enhance RMC. These interventions could be replicated in similar settings to ensure mothers get the respectful care they deserve.