Supportive and Dignified Maternity Care (SDMC) - development and feasibility assessment of an intervention package for public health systems

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Infectious and Tropical Diseases


An increasing number of women in lower- and middle-income countries are giving birth in health facilities. However, a vast majority encounter abusive and disrespectful care which can have immediate and long-term adverse consequences on their lives - and on those of their infants. Emotional distress is common during childbirth, and lack of adequate support for women at this time can adversely affect birth outcomes, and lead to mental problems. There is a global consensus that women attending health facilities for maternity care should be treated with respect and dignity, and provided with informational (e.g. labour progress, techniques to cope with pain) and emotional (e.g. reassurance and praise) support during labour and childbirth. Despite the availability of international guidelines on supportive and dignified care, no service-delivery model currently exists that successfully demonstrates how to incorporate these principles into routine, facility-based maternity care.

Levels of anxiety and depression in Pakistan are the highest in Asia, and recent evidence shows a high rate of reports of disrespect and abuse during childbirth in Pakistan's health facilities. Numerous factors in the running of health systems contribute to this compromised care, among them: lack of awareness and professional capacity of service-providers around respectful and supportive care; a non-conducive work environment; and poor governance and accountability. The main objective of this research is to develop a Supportive and Dignified Maternity Care SDMC service-delivery model, and test its feasibility and acceptability for content and operationalisation in public health facilities in Pakistan.

The Supportive and Dignified Maternity Care (SDMC) service-delivery package has the following components:
a) Engaging with implementers (practitioners, managers, policy-makers and communities) to identify bottlenecks around SDMC, and work collectively to develop capacity-building materials and mechanisms to ensure the implementation of SDMC guidelines in routine service delivery;
b) 'Capacity building' of maternity teams on SDMC to improve understanding and team work for improved patient care;
c) Implementation of 'Collaborative Care' where a team works collectively - its members supporting one another - to ensure internal accountability follow-up, and checks and balances against care-plans, to meet SDMC needs;
d) Orientation of patients (and/or their companions) in the systems and processes of care, and in their SDMC rights;
e) And finally, the accountability component of the model will include record-keeping of women's experiences, periodic reviews of performance in relation to SDMC, and the taking of remedial measures.

For this early-phase research, we will collect extensive data before, during and after the implementation of intervention to assess how successfully SDMC guidelines are practised, and the challenges faced by service-providers. We will also observe changes in women's experiences of supportive and dignified care.

Based on the sound feasibility of the early-stage research - especially its potential to improve maternity-ward processes and practices, and mothers' intrapartum-care experiences - our eventual aim would be to evaluate the effectiveness of the SDMC package through robust, large-scale research and its application in varied health-system settings.

Technical Summary

Poor psycho-social support and demeaning care during childbirth at health facilities are common worldwide, particularly in low- and middle-income countries. Despite a policy directive from the World Health Organisation (WHO), no operational model exists that effectively demonstrates incorporation of these guidelines in routine facility-based maternity services. Recent evidence from Pakistan shows a high rate of reports of disrespect and abuse during childbirth and several health systems factors contribute to this compromised care.
This early-phase research aims to develop, implement, and test the feasibility of a Supportive and Dignified Maternity Care (SDMC) service-delivery model, based on WHO's guiding principles and framework, that promotes respectful and supportive intrapartum care at public health facilities. The components of the SDMC model includes: 1) Participatory and co-created service-delivery intervention; 2) Capacity-building of maternity teams (clinical and support staff) through a 'partnership approach'; 3) Collaborative Care Model; 4) Patient orientation in the processes of care, and their SDMC rights; 5) information system (complaints register); 6) Accountability (exit interviews); and 7) Embedding performance reviews.
Using mixed-method design, and extensive collection of data before, during and after the implementation of the intervention, we will assess the coverage of the intervention, and its fidelity - the extent to which SDMC guidelines are being adhered to. Challenges faced, and changes in maternity teams' understanding and attitude - and in women's maternity experiences and psycho-social well-being - will also inform the success of the intervention.
Evidence from this research will lead to further amendments to the SDMC-model package. It will provide insights about behaviour-change in maternity staff and birthing women, and possible 'effect size' to design a larger evaluation and scalability-research in diverse health-system contexts

Planned Impact

The proposed research targets a significant - yet woefully neglected - component of health systems: the social and emotional needs of women attending health facilities for maternity care. This research builds on a policy directive from the World Health Organisation that identifies respectful and supportive care as a fundamental right of every women. Currently, however, no intervention model exists that demonstrates an ability to implement these principles in routine, facility-based maternity care. Therefore, the key premise of the proposed research is to develop an SDMC service-delivery model through a participatory consensus-driven process, and to test its feasibility and acceptability in public health facilities. The Supportive and Dignified Maternity Care (SDMC) model includes training material and an implementation strategy, and could be used by other researchers and health-system professionals in similar settings.

Healthcare practitioners, programme-managers, policy-makers and women at maternity-care health facilities will be the direct beneficiaries of this project.

Project outputs
A key output from this research will be the SDMC service-delivery package, comprising a comprehensive training package (on respectful and supportive maternity care) and a tested strategy to ensure implementation of recommended practices around supportive and dignified care in routine, facility-based maternity care. There will also be sustained support and facilitation for practitioners and programmers throughout the implementation of SDMC standard guidelines in routine, facility-based maternity care. Furthermore, to ensure wide-spread access to the knowledge generated from this research, policy/research briefs will be written, flyers developed, and dissemination events organised for diverse audiences, including women, practitioners, managers, and policy-makers.

Knowledge advancement
The research will identify key health-system challenges in the provision of supportive and dignified intrapartum care in public health facilities. Moreover, through shared knowledge and the collective effort of researchers and implementers, the research will devise mechanisms that could ensure the administration of, and accountability to, supportive and dignified care. The training material and implementation strategy could be taken to scale (if proven feasible) in other public health facilities across Pakistan.

Implications for research-evidence users
In terms of immediate output, training workshops will be conducted to enhance the professional capacity of health-facility staff on supportive and dignified care, and to ensure provision through collaborative care. Clinical and management staff will receive three days' training, while support staff will receive training for one day. There will be on-going support for the implementation of SDMC principles in routine care provision, following a collaborative care model. The enhancement of capacity is expected to improve knowledge and practices of - and attitudes towards - supportive and dignified care through a team-driven approach which will lead to the improved quality of maternity care, and therefore of the birthing experiences of women.

Direct beneficiaries of the research findings will be the Department of Health, followed by policy-makers and health-system programmers at the national level. Health-managers and policy-makers will develop an understanding of health-system issues that impede the provision of respectful and dignified care. Our findings will serve as the basis for formulating evidence-informed standards and policies that ensure the provision of humanised, respectful, and rights-based care, complemented by psycho-social support.


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Title Posters 
Description As part of the research project, we have developed six posters for maternity wards of public health facilities. The content of these posters were translated in local language and they are mounted at different location within health facilities. For patients and their companions: a) Role of Companion in providing care to pregnant women in health facilities b) Dignified maternity care c) Rights and responsibility of pregnant women and companion For health facility staff d) Psychosocial support for pregnant women e) Psychosocial support for maternity care staff f) SDMC implementation process 
Type Of Art Artwork 
Year Produced 2021 
Impact The impact of these posters is yet to be measured. However, it is expected that these posters will guide and reinforce staff to promote the culture of respect and support in health facilities. 
Description Research still in progress
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
Title SDMC strategy and Inclusive care tool 
Description 1. Supportive and Dignified Maternity Care (SDMC) strategy for maternity team in low and middle income countries: SDMC strategy is a theory-driven, inclusive service-delivery package which is developed using the principles of the human-centred design approach. It aims to improve women's experience of childbirth in public health facilities by promoting supportive and dignified maternity care for all women, with special focus on women with disabilities and on those suffering from common mental disorders (including distress). The strategy includes capacity-building of maternity teams, and the improvement of governance and accountability mechanisms within public health facilities to ensure that all women are treated with compassion and dignity, while also catering for their diverse needs, including disabilities and common mental health conditions. The integration of psychosocial support in routine maternity care is a unique feature of the intervention package, a principal aim of which is to address the psychological needs of birthing women and their companions. 2. Inclusive healthcare tool: Inclusive health refers to the that is responsive to the particular needs of marginalised and/or vulnerable pregnant women (e.g. disabled, poor, etc.), delivered in such a way that overcomes their particular barriers to health. A research instrument was newly developed to collect data from postnatal women to capture if they experience inclusiveness in the care given to them in health facility during childbirth. 
Type Of Material Improvements to research infrastructure 
Year Produced 2020 
Provided To Others? No  
Impact 1. Supportive and Dignified Maternity Care (SDMC) strategy for maternity teams in low and middle income countries: The SDMC strategy is expected to improve women's experience of childbirth in public health facilities by promoting supportive and dignified maternity care for all women, with special focus on women with disabilities and on those suffering from common mental disorders (including distress). The SDMC strategy along with training handbook will be publicly available for use in other countries. 2. Inclusive healthcare tool: The data collection tool will be made public for other researchers to use in their countries. 
Description Lead implementing collaborator 
Organisation Aga Khan University
Country Pakistan 
Sector Academic/University 
PI Contribution The LSHTM is the technical lead for this SDMC project whereas the Aga Khan University (AKU), Pakistan is the implementation lead. AKU is the top ranked academic institution in heath care in Pakistan and has a sound track-record of research over the past 3 decades.
Collaborator Contribution The following contributions made the by partner: a) Development of field protocol b) Data collection (formative, baseline and endline) c) Data management d) Development of training handbook for maternity team e) Trainings of staff
Impact - Project still on-going
Start Year 2019
Description Technical Collaborator 
Organisation University of Karachi
Country Pakistan 
Sector Academic/University 
PI Contribution Mental health (or psychosocial support) was an integral part of our research study. Identifying a local expert who is well acquainted with the context was imperative; hence we reach out one of the most reputed academic institution in Karachi, and established formal collaborative relationship with its Department of Psychology via Aga Khan University (the in-country lead institution in Pakistan for this research).
Collaborator Contribution Dr Bushra Khan (Assistant Professor) at the department of Psychology, University of Karachi played an instrumental role at all stages of the research from conceptualization of training handbook, development of research tools, trainings, and currently involved in supportive supervision and knowledge management activities.
Impact Following are some of the key outputs: a) Training of 7 data collectors for baseline survey b) Development of research instruments such as monitoring checklist for supportive supervision officers
Start Year 2019
Title Supportive and Dignified Maternity Care: Training Handbook for Maternity Teams 
Description SDMC training handbook for maternity team: This capacity building handbook is developed by a group of experts as part of the Supportive and Dignified Maternity Care Project. This handbook aims to strengthen health systems by enhancing the capacity of maternity teams and introducing accountability measures that are geared towards promoting supportive and dignified maternity care (SDMC) in public health facilities. The first draft of the handbook is drafted and approximately 100 maternity staff members have been trained. The handbook is simultaneously being reviewed by local and international experts. The handbook will be finalised after the endline evaluation of SDMC intervention and after incorporating the feedback from local and international experts of this field. This handbook is being developed as part of this SDMC project which is supported by Medical Research Council, United Kingdom 
Type Health and Social Care Services
Current Stage Of Development Initial development
Year Development Stage Completed 2021
Development Status Under active development/distribution
Impact We have trained approximately 100 maternity staff based on the SDMC handbook. The content, including activities, covered in a 3-day training. The overall aim of trainings was to inculcate a positive change in knowledge, attitude and skills for improved care coordination among healthcare workers to promote SDMC, with women with disabilities and with those suffering from compromised mental health conditions. 
Description Engagement with the health system stakeholders in the Sindh province of Pakistan 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other audiences
Results and Impact 1. Continuous engagement with Medical Emergency Resilience Foundation (MERF) and Department of Health (DoH):
Several meetings have taken place with MERF (a local NGO managing operations of public health facilities) and Department of Health, Government of Sindh. The purpose of these meetings included: orientation about the project, discussion on potential ideas about the intervention, taking feedback on the prototype intervention, implementation of intervention, rectification of implementation challenges.

2. Training of maternity team:
As part of the intervention, approximately 100 maternity team of the selected health facilities have been trained on the supportive and dignified maternity care. A total of five trainings were conducted, each spread over 3-days.
Year(s) Of Engagement Activity 2020