An estimated 800 women die every day across the world as a result of pregnancy-related complications. Most deaths (95%) occur in low- and middle-income countries. Two-thirds are in sub-Saharan Africa. For every woman who dies, about 20 others suffer from various pregnancy related complications.
Roughly three-quarters of these deaths result from complications during labour, delivery and the first 24 hours after delivery.
High-quality care during childbirth is critical for preventing maternal and newborn deaths. While a growing number of women are giving birth in health facilities in sub-Saharan African countries like Ghana and Kenya, there are still significant gaps in equity and quality of healthcare. This is true between as well as within countries.
Person-centred reproductive healthcare is critical to improving health outcomes. Yet, research continues to document a lack of person-centred maternity care - which is care that is responsive, respectful and compassionate. Studies show that the most vulnerable groups have the worst experiences. This leads to women not seeking care, or being subjected to delayed, inadequate or harmful care, contributing to high maternal mortality and morbidity.
There is, however, only limited evidence on effective interventions to improve maternal care in low and middle-income countries.
In particular, the role of provider burnout and bias hasn't been explored. Burnout is a state of mental, physical and emotional exhaustion. Bias is a preference for or against one person or group. Burnout leads to poor person-centred maternity care, while bias leads to different care for different patients. To provide high quality care for all women, it's important to address both.
Looking to build evidence about interventions that improve maternal care, our team at the University of California, the Kenya Medical Research Institute and the Global Programs for Research and Training designed and piloted an intervention in Kenya's Migori county in the west. We called it "Caring for Providers to Improve Patient Experience".
This work built on our long history in the county studying the extent of and the drivers of person-centred maternity care. It was informed by our prior findings and literature reviews, as well as our expertise.
We monitored the pilot over six months and found, based on provider reports, that the intervention improved the healthcare experiences of both providers and patients.
These findings are important given the need for interventions to improve both providers' and patients' experiences, with a focus on the most vulnerable women.
Burnout and bias
Burnout is an important predictor of poor patient and provider experiences alike. Burnout can manifest as detachment, cynicism and poor attitude towards patients, leading to poor experiences.
Burnout is caused by prolonged stress from exposure to stressors and environmental factors people don't have control over. For healthcare workers in low-resource settings, these can include: high workload, lack of basic resources, unsupportive work environments, limited skills to manage obstetric and newborn emergencies, and repeated trauma from patient complications or death.
Provider burnout was already high globally and rose to crisis levels during the COVID-19 pandemic. High burnout rates were reported among providers in sub-Saharan Africa.
Bias can be implicit or explicit. It manifests as providing different care based on attributes like socioeconomic status, racial identity, ethnicity and age.
Patients with lower socioeconomic status often have more negative healthcare experiences and providers often spend less time with them than with patients of higher socioeconomic status. This contributes to patients distrusting providers, to not following treatment recommendations and to health disparities. Providers are more likely to be biased when they are stressed.
Caring for healthcare providers
The Caring for Providers to Improve Patient Experience intervention set out to tackle these two drivers of poor care: provider bias and burnout.
The approach integrates multiple strategies: training providers; creating peer support groups; developing a mentorship programme; using embedded champions (who are healthcare workers empowered to serve as change agents); and leadership engagement within health facilities and across the health system.
Our pilot in Migori county had the following results.
- Increased provider knowledge and competency in managing stress and mitigating bias. One participant said:
I now know how to calm down. Am not the bitter nurse I was before. I know how to cope with the stresses that we are going through in the maternity. I can handle difficult cases. The way I use to freeze when I got emergencies, I no longer freeze. I just breathe in and out then I quickly do what is expected of me.
- Decreased stress and burnout. Providers noted changes to their health and wellbeing, and highlighted how learning stress reduction techniques helped them manage anger that would have been directed at patients.
- Increased bias awareness and mitigation behaviours. Providers said they were now more aware of their biases and were taking steps to avoid discrimination based on their perceptions of a patient's social status or appearance. One participant said:
So, initially (when) a mother came very organised we would attend to them very nicely; and those who came unkempt, we would not attend to them well. But now we have realised our mistakes and we no longer treat them based on their appearance.
- Increased accountability to address bias. Because most of the providers participated in the training, they were holding each other accountable.
- Increased provision of person-centred maternity care. Providers noted a positive shift in patient-provider interactions as they became more friendly.
- Improved relationships among providers, leading to a supportive work environment. Providers felt that the intervention made them more collaborative and open with colleagues.
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Previously, we the providers never had time to laugh but after the training, and when we were going on with our refresher training, we would vent our stress and share your experience and you feel good about your work.
- Increased advocacy to address sources of stress. The intervention facilitated collective action and advocacy to address health system issues, such as a lack of supplies.
Scaling up
We are currently running a cluster-randomised controlled trial in Kenya and Ghana. This is a bigger study where some facilities are receiving the intervention and others are part of a control group that will receive the intervention after the study's done. This will assess the impact of the intervention from surveys with mothers.
The Caring for Providers to Improve Patient Experience approach shows great promise in its ability to reduce provider stress and burnout, mitigate the effects of bias and improve person-centred maternal care. And we believe this intervention can be used in other settings in sub-Saharan Africa.
Patience Afulani, Associate professor, University of California, San Francisco
Linnet Ongeri, Principal Clinical Research Scientist, KEMRI Wellcome Trust Research Programme
