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DISRESPECT AND ABUSE: DO POOR KENYAN WOMEN SUFFER MORE?
Charlotte Warren, Charity Ndwiga and Timothy Abuya
GMNH Conference Mexico City 21 October 2015
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Universal Rights of Childbearing Women Disrespect and abuse
during maternity care are a violation of women’s basic human rights
www.whiteribbonalliance.org/respectfulcare
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Heshima Project: Kenya
Research question: Are poor women more likely to receive
disrespectful and abusive care during childbirth? 13 facilities
Exit survey: among women discharged from postnatal wards before and
after intervention
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Drivers of D&A
Final Package of RMC Interventions Outcomes
Improved RMC policy
environment
Reductions in D&A
Community awareness on
rights increased
Outputs
Increased visibility of RMC
as a rights-based approach
RMC resource package
developed for all levels of care
RMC incorporated into Maternal
Health Bill
Advocacy for RMC through
media and champions
- Lacking synergy across sectors
Policy Perspectives
• Implementation gap between MNH policy/guidelines and
practice
• Inadequate community participation in policy process
• Lack of awareness of patient and provider rights (and
obligations)
• Inadequate funding for MNH • Lacking synergy across sectors
• Pre-service curricula lack RMC focus • Limited regulatory
authority (audits &
redress mechanisms)
Drivers of D&A*
*
Heshima Theory of Change
Policy Perspectives
Facility Perspectives
• Practice norms and shared attitudes limit ability to
change
• Infrastructure, limited resources, staffing • High case
load/work-related stress • Lack of awareness of rights and
obligations
in facilities • Insufficient mentorship/supervision •
Inadequate compensation for overtime • Inadequate reporting
systems
Community Perspectives
• Informal payments • Inadequate linkages with facility •
Staffing and infrastructure constraints • Inadequate provider
skills and
knowledge • Inability to 'defend' or 'demand
rightful treatment
Community Perspectives
Facility Perspectives
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Overall prevalence of D&A during labor and delivery at
baseline and endline Category of D&A Baseline
(N=641) Endline (N=728)
OR (95%CI)
Feels humiliated or disrespected**
20.1 (129) 13.2 (96) 0.58 (0.43 – 0.79)
Physical abuse* 4.2 (27) 2.1 (15) 0.47 (0.25 – 0.90) Privacy
violated 7.4 (47) 5.7 (41) 0.69 (0.44 – 1.08) Confidentiality
violated* 3.9 (25) 1.8 (13) 0.45 (0.23 – 0.89) Verbal abuse** 18.0
(115) 11.3 (82) 0.58 (0.42 – 0.80) Detention** 8.0 (51) 0.8 (6)
0.09 (0.04 – 0.22) Abandonment 12.7 (81) 16.9 (122) 1.28 (0.93 –
1.76)
*p
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Comparison of occurrence of any D&A with socio economic
status at baseline
% reporting Focus quintile Remaining quintiles P value
Any Disrespect and Abuse
Lowest 20% Highest 80%
24.2% 19.1% 0.197
Lowest 40% Highest 60%
21.9% 19.0% 0.367
Lowest 60% Highest 40%
20.6% 19.5% 0.729
Highest 20% Lowest 80%
15.5% 21.3% 0.143
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Comparison of highest and lowest quintiles and D&A
experience at baseline
0 5 10 15 20
Others
Lowest 20%
Others
Highest 20%
Abandonment
Non dignified care
Non confiden
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Baseline findings from qualitative interviews
• “I found a woman who had been detained for over a month and
had twins. I felt bad and if I had money could have paid for her
because I pitied her” (Men FGD)
• “It’s about the money you have, with money you can afford to
be treated well and given good services” (Woman FDG)
• …maybe the rich can know where to get lawyers that deal with
such issues, but the poor will not know, and they do not have the
money…
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Endline Any
humilia3on Physical abuse
Detainment Abandonment
AOR (95% CI) AOR (95%
CI) AOR (95% CI) AOR (95%
CI) Wealth Poorest tercile Middle
tercile Richest tercile
Ref 1.33
(0.89 – 1.99) 1.18
(0.76 – 1.83)
Ref † 2.12
(0.95 – 4.71) 0.65
(0.22 – 1.88)
Ref † 0.45
(0.21 – 0.96) 0.22
(0.08 – 0.60 )
Ref †† 1.61
(1.04 – 2.49) 1.30
(0.80 – 2.09) Facility Sector
Government Private/FBO
Ref † 0.37
(0.14 – 0.98)
Ref 1.07
(0.25 – 4.55)
Ref 0.23
(0.03 – 2.12)
Ref 0.52
(0.20 – 1.33) Time of Delivery
Day Night
Ref † 1.37
(1.02 – 1.85)
Ref † 2.51
(1.17 – 5.39)
Ref 1.15
(0.62 – 2.12)
Ref 1.14
(0.84 – 1.56)
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Factors associated with D&A • Young women less likely to
experience non-
confidential care • Higher parity women more likely to be
detained /
asked for bribes • Presence of support/partners was protective
of
detention/asked for bribes • Poorest 20% did not report
physical abuse but felt
abandoned at baseline • Poorer women more likely to be detained
at endline • Women less likely to experience D&A at
private/faith
based • Abuse happens more frequently at night at endline
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Discussion
• Initially SES did not appear to make a difference whether
women received D&A or not
• Women delivering in public health facilities are not the most
well off–so analyzing inequity using quintiles can mask other
findings
• Perhaps poorer women normalise the ‘physical abuse’ - this
issue needs further analysis
• Night time is worse for client (Physical/verbal abuse) •
District with biggest wealth divide had highest D&A
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Study publications
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Acknowledgments • MOH: DRH, Nursing and Midwifery Unit,
Standards
and Regulatory Services Unit, TWG for MNH and HR • USAID
through the TRAction Project/URC • National Nurses Association
Kenya NNAK-MC, • Federation of Women’s Lawyers Kenya (FIDA-K) •
Project Steering Committee: NCK, KMA, KOGS, UON;
School of PH, Dept of ObGyn and Nursing • CSOs: WRA–Kenya,
HERAF • Study site communities, providers and managers • Study
participants especially the women who agreed
to be observed and interviewed
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Phot
o by
Fly
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arre
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urte
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f th
e Po
pula
tion
Cou
ncil
Thankyou
The Population Council conducts biomedical, social science, and
public health research. We deliver solutions that lead to more
effective policies, programs, and technologies that improve lives
around the world http://www.popcouncil.org
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Other factors associated with D&A at baseline
Characteristic Any D&A Detained Request for
bribe Parity: ref: no previous children
Between 1-3 children
1.2(0.59,2.3) p=0.621
3.5 (2.2, 5.9) p
