title: Mitigating disrespect and abuse during childbirth in Tanzania: an exploratory study of the effects of two facility-based interventions in a large public hospital.
abstract: BACKGROUND
  There is emerging evidence that disrespect and abuse (D&A) during facility-based childbirth is prevalent in countries throughout the world and a barrier to achieving good maternal health outcomes. However, much work remains in the identification of effective interventions to prevent and eliminate D&A during facility-based childbirth. This paper describes an exploratory study conducted in a large referral hospital in Dar es Salaam, Tanzania that sought to measure D&A, introduce a package of interventions to reduce its incidence, and evaluate their effectiveness.
  
  
  METHODS
  After extensive consultation with critical constituencies, two discrete interventions were implemented: (1) Open Birth Days (OBD), a birth preparedness and antenatal care education program, and (2) a workshop for healthcare providers based on the Health Workers for Change curriculum. Each intervention was designed to increase knowledge of patient rights and birth preparedness; increase and improve patient-provider and provider-administrator communication; and improve women's experience and provider attitudes. The effects of the interventions were assessed using a pre-post design and a range of tools: pre-post questionnaires for OBD participants and pre-post questionnaires for workshop participants; structured interviews with healthcare providers and administrators; structured interviews with women who gave birth at the study facility; and direct observations of patient-provider interactions during labor and delivery.
  
  
  RESULTS
  Comparisons before and after the interventions showed an increase in patient and provider knowledge of user rights across multiple dimensions, as well as women's knowledge of the labor and delivery process. Women reported feeling better prepared for delivery and provider attitudes towards them improved, with providers reporting higher levels of empathy for the women they serve and better interpersonal relationships. Patients and providers reported improved communication, which direct observations confirmed. Additionally, women reported feeling more empowered and confident during delivery. Provider job satisfaction increased substantially from baseline levels, as did user reports of satisfaction and perceptions of care quality.
  
  
  CONCLUSIONS
  Collectively, the outcomes of this study indicate that the tested interventions have the potential to be successful in promoting outcomes that are prerequisite to reducing disrespect and abuse. However, a more rigorous evaluation is needed to determine the full impact of these interventions.
authors.affiliation: Women and Health Initiative, Department of Global Health and Population, Harvard T.H Chan School of Public Health, Boston, MA, USA. hannah.ratcliffe@mail.harvard.edu.|Ariadne Labs at Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, MA, USA. hannah.ratcliffe@mail.harvard.edu.
authors.forename: Hannah L
authors.initials: HL
authors.lastname: Ratcliffe
authors.affiliation: Women and Health Initiative, Department of Global Health and Population, Harvard T.H Chan School of Public Health, Boston, MA, USA.|Management and Development for Health, Dar es Salaam, Tanzania.
authors.forename: David
authors.initials: D
authors.lastname: Sando
authors.affiliation: Management and Development for Health, Dar es Salaam, Tanzania.
authors.forename: Goodluck Willey
authors.initials: GW
authors.lastname: Lyatuu
authors.affiliation: Management and Development for Health, Dar es Salaam, Tanzania.
authors.forename: Faida
authors.initials: F
authors.lastname: Emil
authors.affiliation: Africa Academy for Public Health, Dar es Salaam, Tanzania.
authors.forename: Mary
authors.initials: M
authors.lastname: Mwanyika-Sando
authors.affiliation: Management and Development for Health, Dar es Salaam, Tanzania.|Africa Academy for Public Health, Dar es Salaam, Tanzania.
authors.forename: Guerino
authors.initials: G
authors.lastname: Chalamilla
authors.affiliation: Women and Health Initiative, Department of Global Health and Population, Harvard T.H Chan School of Public Health, Boston, MA, USA.
authors.forename: Ana
authors.initials: A
authors.lastname: Langer
authors.affiliation: Women and Health Initiative, Department of Global Health and Population, Harvard T.H Chan School of Public Health, Boston, MA, USA.|Boston University School of Public Health, Boston, MA, USA.
authors.forename: Kathleen P
authors.initials: KP
authors.lastname: McDonald
mesh_terms: D000328:Adult; D058445:Bullying / Q000941:ethics / Q000517:prevention & control*; D065246:Culturally Competent Care / Q000941:ethics* / Q000208:ethnology / Q000592:standards; D004496:Education, Continuing; D005260:Female; D005500:Follow-Up Studies; D019538:Health Care Surveys; D006779:Hospitals, Public; D006786:Hospitals, Urban; D006801:Humans; D007588:Job Satisfaction; D036801:Parturition / Q000208:ethnology; D028701:Patient Rights; D017060:Patient Satisfaction / Q000208:ethnology; D018743:Perinatal Care / Q000941:ethics* / Q000592:standards; D000066550:Physical Abuse / Q000941:ethics / Q000208:ethnology / Q000517:prevention & control*; D011247:Pregnancy; D011369:Professional-Patient Relations / Q000941:ethics; D058996:Quality Improvement; D011787:Quality of Health Care; D013636:Tanzania; D000078329:Workforce; D055815:Young Adult
keywords: Disrespect and abuse; Health workers for change; Maternal health; Quality improvement; Quality of care; Respectful maternity care; Tanzania