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

在低收入和中等收入国家，越来越多的妇女在卫生设施中分娩。然而，绝大多数人都会遇到虐待和不尊重的照顾，这可能会对他们的生活以及他们的婴儿产生直接和长期的不良后果。情绪困扰在分娩过程中很常见，在这个时候缺乏对妇女足够的支持会对分娩结果产生不利影响，并导致精神问题。全球一致认为，在卫生机构接受产科护理的妇女应得到尊重和尊严，并在分娩和分娩期间获得信息（如分娩进展、镇痛技术）和情感（如安慰和赞扬）支持。尽管有关于支持性和有尊严的护理的国际准则，但目前还没有一种服务提供模式成功地展示了如何将这些原则纳入常规的、以设施为基础的产科护理。巴基斯坦的焦虑和抑郁水平是亚洲最高的，最近的证据表明，在巴基斯坦的卫生设施中，分娩期间不尊重和虐待的报告比例很高。卫生系统运行中的许多因素导致这种不公平的护理，其中包括：服务提供者缺乏对尊重和支持护理的认识和专业能力；不利的工作环境；以及糟糕的治理和问责制。本研究的主要目标是开发一种支持性和有尊严的产妇护理SDMC服务交付模式，并测试其在巴基斯坦公共卫生设施的内容和运作方面的可行性和可接受性。支持性和有尊严的产妇护理（SDMC）一揽子服务提供包括以下内容：a)与实施者（从业人员、管理人员、政策制定者和社区）合作，确定SDMC的瓶颈，并共同努力制定能力建设材料和机制，以确保在日常服务提供中实施SDMC指南；b)产科团队对SDMC的“能力建设”，以提高理解和团队合作，改善患者护理；c)实施“协作式护理”，即一个团队集体工作——其成员相互支持——以确保内部问责制的跟进，并对护理计划进行检查和平衡，以满足SDMC的需求；d)向患者（和/或其同伴）介绍护理系统和流程，以及他们的SDMC权利；(e)最后，该模式的责任部分将包括记录妇女的经验，定期审查与可持续发展管理有关的业绩，并采取补救措施。在这项早期研究中，我们将在实施干预措施之前、期间和之后收集大量数据，以评估SDMC指南的成功实施情况，以及服务提供商面临的挑战。我们还将观察妇女在支持性和有尊严的护理方面的变化。基于早期研究的合理可行性——特别是其改善产科病房流程和实践以及母亲在产房内护理经验的潜力——我们的最终目标是通过强有力的大规模研究及其在各种卫生系统环境中的应用来评估SDMC一揽子计划的有效性。

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.