Kujawski Stephanie A, Freedman Lynn P, Ramsey Kate, Mbaruku Godfrey, Mbuyita Selemani, Moyo Wema, Kruk Margaret E
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America.
Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York, United States of America.
PLoS Med. 2017 Jul 11;14(7):e1002341. doi: 10.1371/journal.pmed.1002341. eCollection 2017 Jul.
Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women's poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania.
We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21-0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05-0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19-0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings.
After implementation of the combined intervention, the likelihood of women's reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project's facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486.
ISRCTN Registry, ISRCTN 48258486.
在资源匮乏的国家，分娩期间虐待妇女的情况已有记录，这是阻碍产妇利用医疗机构进行分娩的一个因素。关于改善妇女不良体验的干预措施的证据很少。我们评估了一项参与式社区和卫生系统干预措施，以降低坦桑尼亚分娩期间不尊重和虐待行为的发生率。
我们采用前后对比的评估设计来测试减少不尊重和虐待行为的联合干预措施。坦桑尼亚坦噶地区的两家医院被纳入研究，其中1家被随机分配接受干预。在研究机构分娩的妇女有资格参与，并在出院时被招募。在基线期（2011年12月至2012年5月）和干预后（2015年3月至9月）进行了调查。干预措施包括一份客户服务宪章和一个基于机构的质量改进过程，旨在重新定义尊重产妇护理的规范和做法。主要结果是分娩期间任何自我报告的不尊重和虐待经历。我们使用多变量逻辑回归来估计差异模型。在基线期，邀请了2家研究医院分娩后从产科病房出院的2085名妇女参与调查。其中，1388名（66.57%）同意参与。在终期，1680名妇女参与了调查（占被邀请者的72.29%）。该干预措施使妇女在分娩期间经历不尊重和虐待的几率降低了66%（优势比[OR]：0.34，95%置信区间：0.21-0.58，p<0.0001）。最大幅度的降低是身体虐待（OR：0.22，95%置信区间：0.05-0.97，p=0.045）和忽视（OR：0.36，95%置信区间：0.19-0.71，p=0.003）。该研究仅涉及坦桑尼亚的2家医院，因此是一项概念验证研究。未来应开展更大规模的研究，以评估该方法在其他环境中的适用性。
实施联合干预措施后，妇女报告分娩期间受到不尊重待遇的可能性大幅降低。这些结果是在项目促进实施结束近1年后观察到的，表明具有可持续性的潜力。结果表明，一项旨在通过改变护理规范和标准来解决不尊重和虐待行为的参与式社区和卫生系统干预措施，是改善医疗机构中妇女分娩期间待遇的潜在策略。该试验已在国际标准随机对照试验编号注册中心注册，编号为ISRCTN 48258486。
国际标准随机对照试验编号注册中心，ISRCTN 48258486。
