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

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.

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

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.

Beneficiaries
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.