Caring for providers to improve patient experience (CPIPE): intervention development process

A growing body of research has documented disrespectful, abusive, and neglectful treatment of women in facilities during childbirth, as well as the drivers of such mistreatment. Yet, little research exists on effective interventions to improve Person-Centred Maternal Care (PCMC)—care that is respectful and responsive to individual women's preferences, needs, and values. We sought to extend knowledge on interventions to improve PCMC, with a focus on two factors – provider stress and implicit bias – that are driving poor PCMC and contributing to disparities in PCMC. In this paper we describe the process towards the development of the intervention. The intervention design was an iterative process informed by existing literature, behaviour change theory, formative research, and continuous feedback in consultation with key stakeholders. The intervention strategies were informed by the Social Cognitive Theory, Trauma Informed System framework, and the Ecological Perspective. This process resulted in the ‘Caring for Providers to Improve Patient Experience (CPIPE)’ intervention, which has 5 components: provider training, peer support, mentorship, embedded champions, and leadership engagement. The training includes didactic and interactive content on PCMC, stress, burnout, dealing with difficult situations, and bias, with some content integrated into emergency obstetric and neonatal care (EmONC) simulations to enable providers apply concepts in the context of managing an emergency. The other components create an enabling environment for ongoing individual behavior and facility culture change. The pilot study is being implemented in Migori County, Kenya. The CPIPE intervention is an innovative theory and evidence-based intervention that addresses key drivers of poor PCMC and centers the unique needs of vulnerable women as well as that of providers. This intervention will advance the evidence base for interventions to improve PCMC and has great potential to improve equity in PCMC and maternal and neonatal health

Understanding disparities in person-centred maternity care: the potential role of provider implicit and explicit bias.

Studies in low-resource settings have highlighted disparities in person-centred maternity care (PCMC)-respectful and responsive care during childbirth-based on women's socioeconomic status (SES) and other characteristics. Yet few studies have explored factors that may underlie these disparities. In this study, we examined implicit and explicit SES bias in providers' perceptions of women's expectations and behaviours, as well as providers' general views regarding factors influencing differential treatment of women. We conducted a convergent mixed-methods study with 101 maternity providers in western Kenya. Implicit SES bias was measured using an adaptation of the Implicit Association Test (IAT) and explicit SES bias assessed using situationally specific vignettes. Qualitative data provided additional details on the factors contributing to disparities. Results provide evidence for the presence of both implicit and explicit bias related to SES that might influence PCMC. Differential treatment was linked to women's appearance, providers' perceptions of women's attitudes, assumptions about who is more likely to understand or be cooperative, women's ability to advocate for themselves or hold providers accountable, ability to pay for services in a timely manner, as well as situational factors related to stress and burnout. These factors interact in complex ways to produce PCMC disparities, and providing better care to certain groups does not necessarily indicate preference for those groups or a desire to provide better care to them. The findings imply the need for multilevel approaches to addressing disparities in maternity care. This should include provider training on PCMC and their biases, advocacy for women of low SES, accountability mechanisms, and structural and policy changes within health care settings

Sources of stress and coping mechanisms: Experiences of maternal health care providers in Western Kenya

The dynamic and complex nature of care provision predisposes healthcare workers to stress, including physical, emotional, or psychological fatigue due to individual, interpersonal, or organizational factors. We conducted a convergent mixed-methods study with maternity providers to understand their sources of stress and coping mechanisms they adopt. Data were collected in Migori County in western Kenya utilizing quantitative surveys with n = 101 maternity providers and in-depth interviews with a subset of n = 31 providers. We conducted descriptive analyses for the quantitative data. For qualitative data, we conducted thematic analysis, where codes were deductively developed from interview guides, iteratively refined based on emergent data, and applied by a team of five researchers using Dedoose software. Code queries were then analysed to identify themes and organized using the socioecological (SE) framework to present findings at the individual, interpersonal, and organizational levels. Providers reported stress due to high workloads (61%); lack of supplies (37%), poor salary (32%), attitudes of colleagues and superiors (25%), attitudes of patients (21%), and adverse outcomes (16%). Themes from the qualitative analysis mirrored the quantitative analysis with more detailed information on the factors contributing to each and how these sources of stress affect providers and patient outcomes. Coping mechanisms adopted by providers are captured under three themes: addressing stress by oneself, reaching out to others, and seeking help from a higher power. Findings underscore the need to address organizational, interpersonal, and individual level stressors. Strategies are needed to support staff retention, provide adequate resources and incentives for providers, and ultimately improve patient outcomes. Interventions should support and leverage the positive coping mechanisms identified

Self-reported provision of person-centred maternity care among providers in Kenya and Ghana: scale validation and examination of associated factors.

IntroductionPerson-centred maternity care (PCMC), which refers to care that is respectful and responsive to women's preferences needs, and values, is core to high-quality maternal and child health. Provider-reported PCMC provision is a potentially valid means of assessing the extent of PCMC and contributing factors. Our objectives are to assess the psychometric properties of a provider-reported PCMC scale, and to examine levels and factors associated with PCMC provision.MethodsWe used data from two cross-sectional surveys with 236 maternity care providers from Ghana (n=150) and Kenya (n=86). Analysis included factor analysis to assess construct validity and Cronbach's alpha to assess internal consistency of the scale; descriptive analysis to assess extent of PCMC and bivariate and multivariable linear regression to examine factors associated with PCMC.FindingsThe 9-item provider-reported PCMC scale has high construct validity and reliability representing a unidimensional scale with a Cronbach's alpha of 0.72. The average standardised PCMC score for the combined sample was 66.8 (SD: 14.7). PCMC decreased with increasing report of stress and burnout. Compared with providers with no burnout, providers with burnout had lower average PCMC scores (β: -7.30, 95% CI:-11.19 to -3.40 for low burnout and β: -10.86, 95% CI: -17.21 to -4.51 for high burnout). Burnout accounted for over half of the effect of perceived stress on PCMC.ConclusionThe provider PCMC scale is a valid and reliable measure of provider self-reported PCMC and highlights inadequate provision of PCMC in Kenya and Ghana. Provider burnout is a key driver of poor PCMC that needs to be addressed to improve PCMC