International Journal of Gynecology and Obstetrics 127 (2014) S40–S42
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO LOGIC INITIATIVE
Respectful maternity care in three health facilities in Burkina Faso: The experience of the Society of Gynaecologists and Obstetricians of Burkina Faso Ali Ouédraogo a,b,⁎, Sibraogo Kiemtoré a, Hyacinthe Zamané a, Blandine T. Bonané a,b, Michel Akotionga a, Jean Lankoande a,b a b
Society of Gynaecologists and Obstetricians of Burkina Faso, Ouagadougou, Burkina Faso Department of Obstetrics and Gynecology, University of Ouagadougou, Ouagadougou, Burkina Faso
a r t i c l e
i n f o
Keywords: Burkina Faso FIGO LOGIC initiative Health professional association Quality of care Respectful maternity care Society of obstetrics and gynecology
a b s t r a c t The Society of Gynaecologists and Obstetricians of Burkina Faso (SOGOB) conducted a project to reinforce skills in respectful maternity care among its members and health workers at three facilities. The participatory process allowed health workers to self-diagnose quality of care, recognize their own responsibility, propose solutions, and pledge respectful care commitments that were specific for each unit. Key commitments included good reception; humanistic clinical examination; attentive listening and responsiveness to patient needs; privacy, discretion, and confidentiality; availability; and comfort. These commitments can potentially be modified after each evaluation by SOGOB. Poor working conditions were found to negatively impact on quality of care. High staff turnover, frequent technical malfunctions, and inadequate infrastructure were identified as issues that require future focus to ensure improvements in quality of care are sustainable. Programs that aim to improve the maternity experience by linking good practice with humanistic care merit rollout to all healthcare facilities in Burkina Faso. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction
2. Background
Quality improvement remains a priority for health services in lowincome and middle-income countries, where a large proportion of the population often has insufficient access to good-quality health care. Lack of respectful care is an important contributor to insufficiencies in the quality of maternal health services [1,2]. Many strategies to improve maternal and neonatal health services focus on the acquisition of knowledge and technical skills. By contrast, integration of patient rights and satisfaction requires a focus on the interpersonal skills of the relevant health workers. The Society of Gynaecologists and Obstetricians of Burkina Faso (SOGOB) conducted a project that aimed to develop the interpersonal skills of health workers in Burkina Faso. Through the introduction of respectful maternity care, SOGOB sought to improve the interaction between health workers and women in the delivery room.
Reduction of maternal and neonatal mortality is a national priority in Burkina Faso. A number of strategies have been implemented to ensure that the United Nations Millennium Development Goals 4 and 5—which seek to reduce child mortality and improve maternal health, respectively—are met by the target date of 2015 [3]. These strategies include improvement of skills in emergency obstetric and neonatal care; improvement of financial access through the subsidization of both uncomplicated deliveries and emergency maternal and neonatal care; and scaling up of maternal death reviews and family planning. In April 2011, the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health project committee—which comprised representatives from the Burkina Faso Ministry of Health, United Nations Population Fund, WHO, United Nations Children’s Fund, Family Care International, SOGOB, and other health professional associations—prioritized three areas for intervention that would contribute toward appreciable reductions in maternal and neonatal mortality. The key areas targeted by the project committee were skilled birth attendance; essential neonatal care; and respectful care in the delivery room. As SOGOB had already embarked on interventions to tackle the first two areas, the association responded to the
⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Ouagadougou, 03 BP 7021 03 Ouagadougou, Burkina Faso. Tel.: +226 50307064; fax: +226 50307242. E-mail address: [email protected] (A. Ouédraogo).
http://dx.doi.org/10.1016/j.ijgo.2014.07.009 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
A. Ouédraogo et al. / International Journal of Gynecology and Obstetrics 127 (2014) S40–S42
committee’s recommendations by setting up pilot initiatives that aimed to introduce respectful maternity care across three project sites in Burkina Faso. 3. Methodology The present project was conducted by SOGOB in partnership with FIGO LOGIC and with the technical support of Family Care International Burkina. Activities to reinforce skills in respectful maternity care were performed at three health facilities: a primary rural district hospital (Diébougou Disrict), a secondary urban regional hospital (Gaoua regional Hospital), and a tertiary urban university hospital (Yalgado Ouédraogo of Ouagadougou University Hospital). A total of 46 health workers, including obstetricians, obstetricians in training, health assistants (nurses specialized in surgery and anesthesia), and midwives received training at sessions on February 8–10 and May 9–11, 2012, in Ouagadougou. Participants attended one of the two sessions. The second day of training was a study visit to observe interactions between providers and pregnant women in health facilities in Ouagadougou. These three-day training sessions were also attended by six members of SOGOB. SOGOB members were selected based on their experience in clinical training capacity and availability for supervision. The main themes of these sessions were focused on respectful care and interpersonal skills through the use of presentations, group work, role play, and case studies. A health-facility visit on the final day allowed for direct scrutiny of health worker–patient relationships in a clinical setting, and participants were able to observe both respectful and nonrespectful elements of care. The session ended with the formulation of 10 respectful care commitments by the health workers from each of the three project sites. Follow-up visits integrating emergency obstetric and neonatal care, maternal death review, and respectful care in the delivery room were made by members of SOGOB. Follow-up visits at each site were conducted as part of the project activities of the LOGIC initiative from September 17−22, 2012, and May 13−18, 2013. 4. Results Table 1 summarizes the results of direct observations made in the delivery room by providers during training. Both respectful and nonrespectful behaviors were noted, as were the main challenges faced by facility staff. The respectful maternity care commitments formulated by the health workers are presented in Table 2. Health workers from the university hospital (Yalgado Ouédraogo) formulated commitments for three specific subgroups: obstetricians in training, health assistants specialized in surgery, and midwives. Follow-up of trainees by SOGOB reinforced awareness of respectful maternity care among staff and enabled review of practices at each facility. Both achievements and challenges were noted. Achievements included feedback to colleagues who did not follow the training recommendations; commitment of trained health workers; improved cleanliness in the delivery room; ample explanation given to the pregnant
S41
woman before entering the operating theatre; and communication with the parturient before and during the intervention. The main challenges observed included high staff turnover and large numbers of patients in referral centers. For example, at one visit to the university hospital, SOGOB members noted that six delivery tables were occupied, four patients were waiting on chairs, and one patient was waiting on a stretcher following treatment. 5. Discussion The experiences of the present project have allowed SOGOB to develop its knowledge of respectful maternity care. Previous publications indicate that respectful care is a positive practice implemented in many countries, but this concept is currently underdeveloped in Frenchspeaking areas of Africa [1,2,4–6]. This delay is due to the slow translation of recommended best practices into French. During training, plenary discussions allowed participants to identify the negative impacts of nonrespectful care and promote good practice at their institutions. The present study identified several nonrespectful behaviors, including lack of intimacy, lack of information concerning the services on offer, verbal violence, and lack of informed consent. These findings are in line with a literature review of nonrespectful care attitudes [1]. A study by Warren et al. [2] identified three levels of factors that can lead to disrespectful care and abuse; namely, policy and governance; health system; and individual and community. These sets of factors were found to result in low quality of care and underutilization of skilled birth care. Studies conducted in Burkina Faso [7] and Malawi [8] have demonstrated that community involvement in respectful care can improve the use of health facilities. Once implemented, the commitments of health workers become a source of motivation and a contributing factor to improved quality of care. One of the robust recommendations put forward by the health workers is that health personnel should undertake to treat their patients as they would like to be treated themselves. Interpersonal skills warrant increased emphasis in the basic training curriculum of health workers. The follow-up visits conducted in the present study revealed that certain respectful care attitudes were not achieved at all times. Indeed, they often changed depending on which particular health worker was providing the care. Teamwork between the different staff members working in the delivery room must be the foundation of commitments to respectful maternity care [4,6,9]. Productive interprofessional collaboration should integrate different contextual components, such as mutual respect; mutual trust; social cohesion; efficient management of conflicts; open and honest communication; recognition of interdependency; and acceptance of delegated tasks [4]. Some studies point to the key contribution of respectful care to quality of care improvements [1,5]. In Burkina Faso, low investment in infrastructure and equipment are barriers to improvements in quality of care. Lack of intimacy and delays in management negatively influence quality of care and uptake of healthcare services [2,8].
Table 1 Summary of results of direct observations in the delivery room by providers during training.a Compassionate behavior
Non-compassionate behavior
Difficulties
Presence of licensed midwives in labor room Good reception of the parturient Good support provided to the parturient Encouragement Comfort Kindness Communication during examination Explanation provided to the parturient about the process of delivery Support of the parturient in her different needs
Lack of respect for the privacy of the parturient (no screen or curtain provided) Lack of explanation of the presence of students in the labor room Lack of gentleness Lack of kindness Communication challenges between the health workers Verbal abuse (rebuking the parturient with a loud voice)
Insufficient staff Insufficient equipment (e.g. sphygmomanometer, thermometer) Many patients, resulting in congested hallways Failure of air conditioning and fan in the delivery room
a Data were gathered from the maternity wards of three health facilities in the city of Ouagadougou: maternity Sector 15, District Hospital of Bogodogo, and University Hospital Yalgado Ouedraogo.
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A. Ouédraogo et al. / International Journal of Gynecology and Obstetrics 127 (2014) S40–S42
Table 2 Commitments for respectful maternity care at three health facilities in Burkina Faso.a Diébougou District Hospital
I agree to receive the parturient correctly and make her feel comfortable and confident. I pledge to listen to the parturient carefully (and without interruption) and to encourage her to ask questions. I undertake to preserve the patient’s dignity and act with discretion during communication with the parturient. I undertake to answer any questions the parturient may have. I agree to protect the privacy of the parturient. I pledge to examine the parturient correctly. I agree to use appropriate language with the parturient. I pledge to be courteous to the parturient. I pledge to treat the parturient as I would like to be treated. I am committed to providing comfort to the parturient.
Gaoua Regional Hospital
I will reassure the parturient that she is in good hands. I will comfort the parturient. I will examine the parturient gently while communicating with her. I will inform the parturient of her delivery status. I will not reprimand, blame, or judge the parturient. I will encourage the parturient to ask questions and answer questions. I will encourage the parturient to drink if she wants. I will encourage the parturient to call me at any time if needed. I will answer calls, cries, and complaints of the parturient within 2 minutes. I will be patient and tolerant with the parturient and accompanying family regarding any incorrect views.
Yalgado Ouédraogo of Ouagadougou University Hospital Obstetricians in training
Health assistants and Midwives
I will receive the parturient upon arrival. I will help the parturient to sit comfortably. I will put the parturient at ease to instill confidence. I will examine the parturient gently while communicating with her. I will explain politely to the accompanying family members that they must wait outside but that they will be informed of developments as and when they occur. I will organize the medical students to avoid multiple examinations of each parturient. I will try to meet the needs and concerns of the parturient and reassure her. I will inform the parturient if surgery is required and explain the indications of the intervention. I will prevent the access of unnecessary personnel to the delivery room. I will explain the delivery workflow to the parturient.
I will use comprehensible language. I will be aware of requests made by the parturient. I will not talk in public about personal issues concerning the parturient. I agree to cover the genitals of the parturient. I will observe the parturient for signs of fear, anger, stress, exhaustion, and pain. I will be kind and empathize with the parturient on a one-to-one basis. I will always explain what I am going to do before performing an abdominal examination. I will tell the parturient what I found during an examination. I will explain to the parturient what she should expect during and after surgery. I will explain to the parturient and family members what they need to do to help the parturient during surgery.
a The commitments were formulated by health workers from each of the three facilities at the training sessions provided by the Society of Gynaecologists and Obstetricians of Burkina Faso.
Improving skills in both emergency obstetric and neonatal care and in respectful maternity care can only improve measures of quality care when linked to effective advocacy for adherence to international standards in the work environment. A combined effort is essential in this regard. The main challenges that must be overcome to enable successful introduction of respectful care in the delivery room are those associated with policy and governance; resources; management; knowledge and skills; attitude; and the community [1]. Analysis of these factors highlights challenges linked with the non-integration of respectful care in the current best practices curriculum in Burkina Faso. First, resources for infrastructure are too limited to attain minimum standards. Second, the attitudes of health workers during healthcare delivery are not always positive. And last, but not least, efforts must be made to improve involvement of the community in the health service. Respectful care is good practice that deserves to be taught. Indeed, respectful care comprises part of a set of six objectives that aim to improve quality of care in the USA by 2020 [10]. The US objectives indicate that all mothers and newborns should benefit from care that is safe, effective, timely, efficient, and equitable. This approach typifies maternity care that is centered on the woman and her family. Following their experience of implementing respectful maternity care practices in three facilities in Burkina Faso, SOGOB formulated two key lessons learned. First, a participative approach to learning interpersonal skills contributes to improved quality of care and motivation of the workforce. Second, a suboptimum working environment negatively impacts on quality of care. The working environment should, therefore, facilitate a strong interaction between health workers and patients in the delivery room. Numerous emergencies occurring in a small confined space do not allow for the provision of respectful maternity care. 6. Conclusion The SOGOB pilot program to improve quality of maternity care by combining good practices with respectful behaviors merits expansion to health facilities across Burkina Faso. A plea should be made to all stakeholders (political, technical, and financial), as well as to health
workers and the community, to ensure that favorable conditions are in place to guarantee the future success of this effort. Acknowledgments The Society of Gynaecologists and Obstetricians of Burkina Faso thanks the FIGO LOGIC initiative team for organizational and financial support. Conflict of interest The authors have no conflicts of interest. References [1] Reis V, Deller B, Carr C, Smith J. Respectful maternity care. Country experiences survey report November 2012. https://www.k4health.org/sites/default/files/RMC% 20Survey%20Report_0.pdf. Published 2012. Accessed June 19, 2014. [2] Warren C, Njuki R, Abuya T, Ndwiga C, Maingi G, Serwanga J, et al. Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya. BMC Pregnancy Childbirth 2013;13:21. [3] World Health Organization. Millennium Development Goals (MDGs). http://www. who.int/topics/millennium_development_goals/en/. Accessed July 9, 2014. [4] Downe S, Finlayson K, Fleming A. Creating a collaborative culture in maternity care. J Midwifery Womens Health 2010;55(3):250–4. [5] Iida M, Horiuchi S, Porter SE. The relationship between women-centred care and women’s birth experiences: a comparison between birth centres, clinics, and hospitals in Japan. Midwifery 2012;28(4):458–65. [6] Lyndon A, Zlatnik MG, Wachter RM. Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet Gynecol 2011;205(2):91–6. [7] Brazier E, Andrzejewski C, Perkins ME, Themmen EM, Knight RJ, Bassane B. Improving poor women’s access to maternity care: findings from a primary care intervention in Burkina Faso. Soc Sci Med 2009;69(5):682–90. [8] Lule GS, Tugumisirize, Ndekha M. Quality of care and its effects on utilisation of maternity services at health centre level. East Afr Med J 2000;77(5):250–5. [9] Hutchison MS, Ennis L, Shaw-Battista J, Delgado A, Myers K, Cragin L, et al. Great minds don’t think alike: collaborative maternity care at San Francisco General Hospital. Obstet Gynecol 2011;118(3):678–82. [10] Transforming Maternity Care Vision Team, Carter MC, Corry M, Delbanco S, Foster TC, Friedland R, et al. 2020 Vision for a high-quality, high-value maternity care system. Womens Health Issues 2010;20(Suppl. 1):S7–S17.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO LOGIC INITIATIVE
Respectful maternity care in three health facilities in Burkina Faso: The experience of the Society of Gynaecologists and Obstetricians of Burkina Faso Ali Ouédraogo a,b,⁎, Sibraogo Kiemtoré a, Hyacinthe Zamané a, Blandine T. Bonané a,b, Michel Akotionga a, Jean Lankoande a,b a b
Society of Gynaecologists and Obstetricians of Burkina Faso, Ouagadougou, Burkina Faso Department of Obstetrics and Gynecology, University of Ouagadougou, Ouagadougou, Burkina Faso
a r t i c l e
i n f o
Keywords: Burkina Faso FIGO LOGIC initiative Health professional association Quality of care Respectful maternity care Society of obstetrics and gynecology
a b s t r a c t The Society of Gynaecologists and Obstetricians of Burkina Faso (SOGOB) conducted a project to reinforce skills in respectful maternity care among its members and health workers at three facilities. The participatory process allowed health workers to self-diagnose quality of care, recognize their own responsibility, propose solutions, and pledge respectful care commitments that were specific for each unit. Key commitments included good reception; humanistic clinical examination; attentive listening and responsiveness to patient needs; privacy, discretion, and confidentiality; availability; and comfort. These commitments can potentially be modified after each evaluation by SOGOB. Poor working conditions were found to negatively impact on quality of care. High staff turnover, frequent technical malfunctions, and inadequate infrastructure were identified as issues that require future focus to ensure improvements in quality of care are sustainable. Programs that aim to improve the maternity experience by linking good practice with humanistic care merit rollout to all healthcare facilities in Burkina Faso. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Introduction
2. Background
Quality improvement remains a priority for health services in lowincome and middle-income countries, where a large proportion of the population often has insufficient access to good-quality health care. Lack of respectful care is an important contributor to insufficiencies in the quality of maternal health services [1,2]. Many strategies to improve maternal and neonatal health services focus on the acquisition of knowledge and technical skills. By contrast, integration of patient rights and satisfaction requires a focus on the interpersonal skills of the relevant health workers. The Society of Gynaecologists and Obstetricians of Burkina Faso (SOGOB) conducted a project that aimed to develop the interpersonal skills of health workers in Burkina Faso. Through the introduction of respectful maternity care, SOGOB sought to improve the interaction between health workers and women in the delivery room.
Reduction of maternal and neonatal mortality is a national priority in Burkina Faso. A number of strategies have been implemented to ensure that the United Nations Millennium Development Goals 4 and 5—which seek to reduce child mortality and improve maternal health, respectively—are met by the target date of 2015 [3]. These strategies include improvement of skills in emergency obstetric and neonatal care; improvement of financial access through the subsidization of both uncomplicated deliveries and emergency maternal and neonatal care; and scaling up of maternal death reviews and family planning. In April 2011, the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health project committee—which comprised representatives from the Burkina Faso Ministry of Health, United Nations Population Fund, WHO, United Nations Children’s Fund, Family Care International, SOGOB, and other health professional associations—prioritized three areas for intervention that would contribute toward appreciable reductions in maternal and neonatal mortality. The key areas targeted by the project committee were skilled birth attendance; essential neonatal care; and respectful care in the delivery room. As SOGOB had already embarked on interventions to tackle the first two areas, the association responded to the
⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Ouagadougou, 03 BP 7021 03 Ouagadougou, Burkina Faso. Tel.: +226 50307064; fax: +226 50307242. E-mail address: [email protected] (A. Ouédraogo).
http://dx.doi.org/10.1016/j.ijgo.2014.07.009 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
A. Ouédraogo et al. / International Journal of Gynecology and Obstetrics 127 (2014) S40–S42
committee’s recommendations by setting up pilot initiatives that aimed to introduce respectful maternity care across three project sites in Burkina Faso. 3. Methodology The present project was conducted by SOGOB in partnership with FIGO LOGIC and with the technical support of Family Care International Burkina. Activities to reinforce skills in respectful maternity care were performed at three health facilities: a primary rural district hospital (Diébougou Disrict), a secondary urban regional hospital (Gaoua regional Hospital), and a tertiary urban university hospital (Yalgado Ouédraogo of Ouagadougou University Hospital). A total of 46 health workers, including obstetricians, obstetricians in training, health assistants (nurses specialized in surgery and anesthesia), and midwives received training at sessions on February 8–10 and May 9–11, 2012, in Ouagadougou. Participants attended one of the two sessions. The second day of training was a study visit to observe interactions between providers and pregnant women in health facilities in Ouagadougou. These three-day training sessions were also attended by six members of SOGOB. SOGOB members were selected based on their experience in clinical training capacity and availability for supervision. The main themes of these sessions were focused on respectful care and interpersonal skills through the use of presentations, group work, role play, and case studies. A health-facility visit on the final day allowed for direct scrutiny of health worker–patient relationships in a clinical setting, and participants were able to observe both respectful and nonrespectful elements of care. The session ended with the formulation of 10 respectful care commitments by the health workers from each of the three project sites. Follow-up visits integrating emergency obstetric and neonatal care, maternal death review, and respectful care in the delivery room were made by members of SOGOB. Follow-up visits at each site were conducted as part of the project activities of the LOGIC initiative from September 17−22, 2012, and May 13−18, 2013. 4. Results Table 1 summarizes the results of direct observations made in the delivery room by providers during training. Both respectful and nonrespectful behaviors were noted, as were the main challenges faced by facility staff. The respectful maternity care commitments formulated by the health workers are presented in Table 2. Health workers from the university hospital (Yalgado Ouédraogo) formulated commitments for three specific subgroups: obstetricians in training, health assistants specialized in surgery, and midwives. Follow-up of trainees by SOGOB reinforced awareness of respectful maternity care among staff and enabled review of practices at each facility. Both achievements and challenges were noted. Achievements included feedback to colleagues who did not follow the training recommendations; commitment of trained health workers; improved cleanliness in the delivery room; ample explanation given to the pregnant
S41
woman before entering the operating theatre; and communication with the parturient before and during the intervention. The main challenges observed included high staff turnover and large numbers of patients in referral centers. For example, at one visit to the university hospital, SOGOB members noted that six delivery tables were occupied, four patients were waiting on chairs, and one patient was waiting on a stretcher following treatment. 5. Discussion The experiences of the present project have allowed SOGOB to develop its knowledge of respectful maternity care. Previous publications indicate that respectful care is a positive practice implemented in many countries, but this concept is currently underdeveloped in Frenchspeaking areas of Africa [1,2,4–6]. This delay is due to the slow translation of recommended best practices into French. During training, plenary discussions allowed participants to identify the negative impacts of nonrespectful care and promote good practice at their institutions. The present study identified several nonrespectful behaviors, including lack of intimacy, lack of information concerning the services on offer, verbal violence, and lack of informed consent. These findings are in line with a literature review of nonrespectful care attitudes [1]. A study by Warren et al. [2] identified three levels of factors that can lead to disrespectful care and abuse; namely, policy and governance; health system; and individual and community. These sets of factors were found to result in low quality of care and underutilization of skilled birth care. Studies conducted in Burkina Faso [7] and Malawi [8] have demonstrated that community involvement in respectful care can improve the use of health facilities. Once implemented, the commitments of health workers become a source of motivation and a contributing factor to improved quality of care. One of the robust recommendations put forward by the health workers is that health personnel should undertake to treat their patients as they would like to be treated themselves. Interpersonal skills warrant increased emphasis in the basic training curriculum of health workers. The follow-up visits conducted in the present study revealed that certain respectful care attitudes were not achieved at all times. Indeed, they often changed depending on which particular health worker was providing the care. Teamwork between the different staff members working in the delivery room must be the foundation of commitments to respectful maternity care [4,6,9]. Productive interprofessional collaboration should integrate different contextual components, such as mutual respect; mutual trust; social cohesion; efficient management of conflicts; open and honest communication; recognition of interdependency; and acceptance of delegated tasks [4]. Some studies point to the key contribution of respectful care to quality of care improvements [1,5]. In Burkina Faso, low investment in infrastructure and equipment are barriers to improvements in quality of care. Lack of intimacy and delays in management negatively influence quality of care and uptake of healthcare services [2,8].
Table 1 Summary of results of direct observations in the delivery room by providers during training.a Compassionate behavior
Non-compassionate behavior
Difficulties
Presence of licensed midwives in labor room Good reception of the parturient Good support provided to the parturient Encouragement Comfort Kindness Communication during examination Explanation provided to the parturient about the process of delivery Support of the parturient in her different needs
Lack of respect for the privacy of the parturient (no screen or curtain provided) Lack of explanation of the presence of students in the labor room Lack of gentleness Lack of kindness Communication challenges between the health workers Verbal abuse (rebuking the parturient with a loud voice)
Insufficient staff Insufficient equipment (e.g. sphygmomanometer, thermometer) Many patients, resulting in congested hallways Failure of air conditioning and fan in the delivery room
a Data were gathered from the maternity wards of three health facilities in the city of Ouagadougou: maternity Sector 15, District Hospital of Bogodogo, and University Hospital Yalgado Ouedraogo.
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A. Ouédraogo et al. / International Journal of Gynecology and Obstetrics 127 (2014) S40–S42
Table 2 Commitments for respectful maternity care at three health facilities in Burkina Faso.a Diébougou District Hospital
I agree to receive the parturient correctly and make her feel comfortable and confident. I pledge to listen to the parturient carefully (and without interruption) and to encourage her to ask questions. I undertake to preserve the patient’s dignity and act with discretion during communication with the parturient. I undertake to answer any questions the parturient may have. I agree to protect the privacy of the parturient. I pledge to examine the parturient correctly. I agree to use appropriate language with the parturient. I pledge to be courteous to the parturient. I pledge to treat the parturient as I would like to be treated. I am committed to providing comfort to the parturient.
Gaoua Regional Hospital
I will reassure the parturient that she is in good hands. I will comfort the parturient. I will examine the parturient gently while communicating with her. I will inform the parturient of her delivery status. I will not reprimand, blame, or judge the parturient. I will encourage the parturient to ask questions and answer questions. I will encourage the parturient to drink if she wants. I will encourage the parturient to call me at any time if needed. I will answer calls, cries, and complaints of the parturient within 2 minutes. I will be patient and tolerant with the parturient and accompanying family regarding any incorrect views.
Yalgado Ouédraogo of Ouagadougou University Hospital Obstetricians in training
Health assistants and Midwives
I will receive the parturient upon arrival. I will help the parturient to sit comfortably. I will put the parturient at ease to instill confidence. I will examine the parturient gently while communicating with her. I will explain politely to the accompanying family members that they must wait outside but that they will be informed of developments as and when they occur. I will organize the medical students to avoid multiple examinations of each parturient. I will try to meet the needs and concerns of the parturient and reassure her. I will inform the parturient if surgery is required and explain the indications of the intervention. I will prevent the access of unnecessary personnel to the delivery room. I will explain the delivery workflow to the parturient.
I will use comprehensible language. I will be aware of requests made by the parturient. I will not talk in public about personal issues concerning the parturient. I agree to cover the genitals of the parturient. I will observe the parturient for signs of fear, anger, stress, exhaustion, and pain. I will be kind and empathize with the parturient on a one-to-one basis. I will always explain what I am going to do before performing an abdominal examination. I will tell the parturient what I found during an examination. I will explain to the parturient what she should expect during and after surgery. I will explain to the parturient and family members what they need to do to help the parturient during surgery.
a The commitments were formulated by health workers from each of the three facilities at the training sessions provided by the Society of Gynaecologists and Obstetricians of Burkina Faso.
Improving skills in both emergency obstetric and neonatal care and in respectful maternity care can only improve measures of quality care when linked to effective advocacy for adherence to international standards in the work environment. A combined effort is essential in this regard. The main challenges that must be overcome to enable successful introduction of respectful care in the delivery room are those associated with policy and governance; resources; management; knowledge and skills; attitude; and the community [1]. Analysis of these factors highlights challenges linked with the non-integration of respectful care in the current best practices curriculum in Burkina Faso. First, resources for infrastructure are too limited to attain minimum standards. Second, the attitudes of health workers during healthcare delivery are not always positive. And last, but not least, efforts must be made to improve involvement of the community in the health service. Respectful care is good practice that deserves to be taught. Indeed, respectful care comprises part of a set of six objectives that aim to improve quality of care in the USA by 2020 [10]. The US objectives indicate that all mothers and newborns should benefit from care that is safe, effective, timely, efficient, and equitable. This approach typifies maternity care that is centered on the woman and her family. Following their experience of implementing respectful maternity care practices in three facilities in Burkina Faso, SOGOB formulated two key lessons learned. First, a participative approach to learning interpersonal skills contributes to improved quality of care and motivation of the workforce. Second, a suboptimum working environment negatively impacts on quality of care. The working environment should, therefore, facilitate a strong interaction between health workers and patients in the delivery room. Numerous emergencies occurring in a small confined space do not allow for the provision of respectful maternity care. 6. Conclusion The SOGOB pilot program to improve quality of maternity care by combining good practices with respectful behaviors merits expansion to health facilities across Burkina Faso. A plea should be made to all stakeholders (political, technical, and financial), as well as to health
workers and the community, to ensure that favorable conditions are in place to guarantee the future success of this effort. Acknowledgments The Society of Gynaecologists and Obstetricians of Burkina Faso thanks the FIGO LOGIC initiative team for organizational and financial support. Conflict of interest The authors have no conflicts of interest. References [1] Reis V, Deller B, Carr C, Smith J. Respectful maternity care. Country experiences survey report November 2012. https://www.k4health.org/sites/default/files/RMC% 20Survey%20Report_0.pdf. Published 2012. Accessed June 19, 2014. [2] Warren C, Njuki R, Abuya T, Ndwiga C, Maingi G, Serwanga J, et al. Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya. BMC Pregnancy Childbirth 2013;13:21. [3] World Health Organization. Millennium Development Goals (MDGs). http://www. who.int/topics/millennium_development_goals/en/. Accessed July 9, 2014. [4] Downe S, Finlayson K, Fleming A. Creating a collaborative culture in maternity care. J Midwifery Womens Health 2010;55(3):250–4. [5] Iida M, Horiuchi S, Porter SE. The relationship between women-centred care and women’s birth experiences: a comparison between birth centres, clinics, and hospitals in Japan. Midwifery 2012;28(4):458–65. [6] Lyndon A, Zlatnik MG, Wachter RM. Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet Gynecol 2011;205(2):91–6. [7] Brazier E, Andrzejewski C, Perkins ME, Themmen EM, Knight RJ, Bassane B. Improving poor women’s access to maternity care: findings from a primary care intervention in Burkina Faso. Soc Sci Med 2009;69(5):682–90. [8] Lule GS, Tugumisirize, Ndekha M. Quality of care and its effects on utilisation of maternity services at health centre level. East Afr Med J 2000;77(5):250–5. [9] Hutchison MS, Ennis L, Shaw-Battista J, Delgado A, Myers K, Cragin L, et al. Great minds don’t think alike: collaborative maternity care at San Francisco General Hospital. Obstet Gynecol 2011;118(3):678–82. [10] Transforming Maternity Care Vision Team, Carter MC, Corry M, Delbanco S, Foster TC, Friedland R, et al. 2020 Vision for a high-quality, high-value maternity care system. Womens Health Issues 2010;20(Suppl. 1):S7–S17.
