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What determines trust in maternity care?: a cross perspec5ve explora5on in periurban Kenya Pooja Sripad Mexico City, Mexico 20 th October, 2015

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Page 1: Whatdeterminestrustinmaternitycare?:across perspec5ve ... · Whatdeterminestrustinmaternitycare?:across perspec5ve%exploraonin periurbanKenya% % Pooja%Sripad% % Mexico%City,%Mexico%

What  determines  trust  in  maternity  care?:  a  cross-­‐perspec5ve  explora5on  in  peri-­‐urban  Kenya  

 Pooja  Sripad  

 

Mexico  City,  Mexico  20th  October,  2015  

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“If  you  don’t  trust  an  institution,  you  won’t  go  there  for  whatever  service.  Only  if  you  don’t  trust  the  hospital,  then  it’s  really  grave  because  in  a  hospital  it  sometimes  

is  between  life  and  death.”    (Medical  of,icer)  

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Background:  Trust  

•  The  belief  that  one’s  expecta9ons  will  be  met  by  an  individual  or  system      

•  Offers  insight  into  –  percep9ons  of  interac9ons  –  power  differen9als    –  inequi9es  in  health  experience  

 

 

•  Kenya:  a  “nested”  understanding  

 

Trust  in  maternity  care  

Confidence  Communica9on  Integrity  Mutual  Respect  Competence  Confiden9ality  Fairness  Systems  Trust    

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Background:  Kenya  Context  •  Maternal  health  

–  MMR:  488  deaths/100,000  live  births  –  61%  women  deliver  in  facili9es    –  20%  report  disrespect  and  abuse  during  facility  

delivery  

•  Heshima  Project  (‘promo9ng  dignity’)    –  Organic  emergence  of  “trust”    

•  Relevant  poli9cal  history  –  Culture  of  impunity  –  New  Cons9tu9on  (2010)  –  Devolu9on  (roll  out  2013)  –  Free-­‐maternity  policy  (June  2013)  

 

   

Sta9s9cs  Sources:  (KDHS  2008-­‐09;    KDHS  2015;    Abyua,  et  al.,  2015)    

Source:  hdp://www.mapsofworld.com/kenya/kenya-­‐poli9cal-­‐map.html  

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Research  Ques9on  

•  What  determines  trust  in  a  maternity  segng?    

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Study  segng:  peri-­‐urban  county  

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Qualita9ve  approach  

•  Theories:  apprecia9ve  inquiry  and  ins9tu9onal  ethnography      

“Women  &  community”  

“Providers  &  Management”  

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Qualita9ve  Process  

Data  collec5on  &  management  •  Introduc9ons    &  consent  

•  Guided  FGD/IDI  

•  Brief  ques9onnaire  

•  Audio-­‐recording,  transcrip9on,  &  transla9on  

Data  analysis  •  Constant  comparison  method  

•  Concurrent  ini9al  followed  by  final  textual  analysis  –  In-­‐depth  fieldnotes  –  Reading  transcripts  –  Induc9ve  coding    –  Memo-­‐wri9ng  

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Key  findings  

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Trust  in  Maternity  Segng  

•  Prior  experience    •  Perceived  risk  or  harm  •  Childbirth  outcomes  •  Maternity  care  literacy  

 

•  Empathy  &  respect  •  Personalized  aden9on  &  care  •  Perceived  ability  of  provider  •  Discrimina9on    •  Corrup9on  

•  Responsiveness  in  emergencies  &  “good  services”  •  Physical  environment  &  cleanliness  •  Navigability  of  processes  •  Management  and  oversight  •  Discrimina9on    •  Corrup9on  •  Coordina9on  amongst  providers  

•  Reputa9on  &  social  history  •  Corrup9on  •  Informa9on  channels    (social  networks,  CHW  

promo9on,  media)  •  Maternity  care  literacy  

 

•  Ac9ons  align  with  expecta9ons  •  Adapt  to  policy  changes  •  Community  voice  •  Intra-­‐facility  feedback    

Provider  factors  

Pa9ent/  individual  factors  

Health  facility  factors  

Community  factors  

•  Ins9tu9onal  hierarchies  •  Policies  and  professional  prac9ce  

codes  •  Devolu9on  

ACCOUNTABILITY  

  STRUCTURAL  FACTORS  

Figure:  Mul+-­‐faceted  trust  determinants  in  the  maternity  se7ng  

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Pa9ent/individual  factors  

Women  &  Community    

 

Providers  &  Management  

 “(R1):  There  are  also  diseases  like  HIV.    When  one  delivers  in  hospital,  it  is  not  easy  for  the  baby  to  get  infected.    Also,  they  [TBAs]  use  things  like  razorblades,  and  in  the  process,  one  may  cut  themselves  and  infect  the  baby.”    (Male  partners,  FGD)  

“I  have  faith...  even  if  you  mistreat  me…the  baby  will  be  well”    (RDW  in  a  facility)  

“a  woman  came  to  deliver  and  had  a  very  bad  experience.  She  carries  forward  that  bad  experience  to  the  next  delivery  .”    (Medical  officer)  

“Some  mothers  come  without  knowing  the  role  of  a  nurse  or  the  role  of  a  doctor…So  some+mes  they  accuse  the  nurses  for  things  which  are  beyond  our  capability.”    (Nurse-­‐midwife)  

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Community  Factors  

•  Social  history  &  reputa9on  

•  Informa9on  channels    –  Social  networks  –  CHWs  –  Media  

 

“(R1):  You  get  prepared  psychologically  [from  conversa+ons].  If  you  get  a  certain  feeling  while  at  home,  you  may  not  be  sure  what  it  is.    But  not  if  one  who  has  gone  through  such  a  thing  has  already  told  you  of  it.  (R2):  It  helps  you  to  be  prepared.”  (1st  9me  pregnant  women,  FGD)  

“An  experience  you  or  someone  else  had  there  that  caused  you  to  either  trust  it  or  not  trust  it.  Its  history.”  (Male  partner,  FGD)  

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Provider  factors  Women  &  Community   Providers  &  Management  

“That  is  a  good  doctor,  a  doctor  who  does  not  discriminate  against  anybody.  You  look  at  her  when  she  is  talking  to  you  –  or  to  another  person  –  she  does  not  have  a  bad  heart.”  (RDW,  IDI)  

 “They  take  you  in  immediately...    They  examine  you  to  know  how  close  you  are  to  delivery….  they  don’t  leave  you.  They  stay  around  and  come  quickly  when  it’s  +me  for  you  to  deliver.    They  later  then  make  you  tea,  and  show  you  to  a  bed  with  your  baby  where  they  cover  you.  They  keep  checking  on  you  frequently  +ll  you  leave  the  hospital.”  (RDW  in  facility,  FGD)  

You  [the  midwife]  are  alone  and  you  have  to  handle  all  those  cases  and  out  of  that  tension,  you  want  the  mother  to  behave  right  the  way  so  you  kind  of  end  up  shou>ng  at  the  mother.    (Facility  matron)  

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Health  facility  factors  •  “good  services”  and  responsiveness  in  emergencies    

•  Physical  and  material  resource  environment    –  Infrastructure,  space,  cleanliness,  beds,  ancillary  care,  supplies  chains,  drugs  

 •  Human  resources:  morale,  management,  oversight,  supervision  

•  Navigability  of  facility  processes  (e.g.  unclear  payment  mechanisms)    

•  Corrup9on  

•  Coordina9on  amongst  providers  

 

“pa+ents  are  very  innocent.  Some+mes  they  come  and  whoever  is  aWending  might  ask  for  some  money  -­‐  nobody  will  know  because  they  are  alone  in  the  room....  So  pa+ents  should  also  know  their  rights  and  they  should  know  that  if  they  pay  for  anything  they  should  be  given  a  receipt.”  (Nurse-­‐midwife)  

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Accountability  

•  Women’s  expecta9ons  align  with  facility  ac9ons  

•  Facility  ability  to  respond  to  free  maternity  

•  Engage  voices  to  ensure  facility  responsiveness  – Women  &  community  –  Frontline  providers    

“if  we  are  expected  to  serve  these  pa+ents  well…  somebody  somewhere  should  listen  to  me.”      (Nurse-­‐midwife)  

“I  think  that  will  help  in  a  big  way  for  women  who  are  underprivileged…But  also,  I  feel  like  the  services  could  deteriorate…I  feel  like  if  someone  could  insult  you  now  during  delivery  yet  you  pay  for  the  service.  So  when  they  know  you  didn’t  pay,  won’t  they  insult  you  more?  ….”  (RDW,  IDI)  

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Structural  factors  •  Ins9tu9onal  hierarchies  

   

•  Devolu9on    

“it’s  just  that  doctor-­‐nurse  rela+onship…  ‘I  am  more  superior  cause  am  a  doctor’  …I  think  every  individual  deserves  respect.”    (Medical  officer)    

“You  cannot  stand  back  and  wait  for  a  pa+ent  to  be  mismanaged  just  because  somebody  is  a  doctor…you  have  to  correct  them...It’s  difficult,  it’s  a  man  [says  empha+cally]  bringing  you  down…”  (Nurse-­‐midwife,  in-­‐charge)  

“They  are  s+ll  at  that  stage  of  trying  to  nego+ate  to  see  who  will  be  where,  how  will  it  be  done…  it  is  important  to  have  some  structure  between  the  county  and  the  health  facility  levels.”  (DPHO)  

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Summary  and  Implica9ons  •  Theory  and  perspec9ve  enable  understanding  of  what  affects  trust  in  the  

maternity  segng  

•  Factor  clusters  relate  to  each  other  and  affect  trust  in  more  than  one  way    

•  Mul9-­‐faceted  determinants  demand  a  complex  set  of  trust  building  mechanisms  

•  Future  research  needed  –  Compara9ve  inquiry  of  framework    –  Interac9ons  between  factor  clusters  and  determinant  saliency  –  Social  networks  and  trust  

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Conclusion  

•  Trust  is  an  important  lens  for  maternity  care  and  health  systems  

•  Trust  has  many  determinants  that  may  interact  in  complex  ways  

•  Poli9cs  of  health  care  segngs  have  implica9ons  for  trust  

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Acknowledgements  •  Study  par9cipants  

•  Thesis  commidee  and  readers  (JHSPH)  –  Maria  MerriI  (advisor)*  –  Robert  Lawrence    –  Deanna  Kerrigan*    –  Sachiko  Ozawa*  –  Larissa  Jennings*  

•  Popula9on  Council    –  CharloIe  Warren*  –  Timothy  Abuya*  –  Charity  Ndwiga*  –  Janet  Munyasa  –  Jackie  Kivunaga  

•  Research  Assistants  –  Brigide  Nelima  –  Florence  Thungu  –  Helen  Chepkorir  Tanui  –  Grace  Rogena  –  Dennis    Bravo  Adipo    –  Rose  Shivambo  

•  USAID  TRAc9on    •  Global  Maternal  Newborn  Health  Conference    

2015  Conference  Organizers  

*  Co-­‐authors  on  abstract  

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Asante!/Thank  you!/Gracias!    

Ques5ons?  /Preguntas?