Pre-post implementation survey of a multicomponent intervention to improve informed consent for caesarean section in Southern Malawi

Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review

BACKGROUND

Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs).

OBJECTIVES

To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature.

SEARCH STRATEGY

The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS.

SELECTION CRITERIA

English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included.

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework.

MAIN RESULTS

Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels.

CONCLUSIONS

There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.

Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort study in a national referral hospital

BACKGROUND

In a critical obstetric situation, the time interval between the decision of performing a caesarean section (CS) and delivery can influence maternal and newborn outcomes. In Somaliland, consent for surgical procedures, such as CS needs to be sought from family members.

OBJECTIVE

To determine the association between a delay in performing a CS and severe maternal and newborn outcomes in a national referral hospital in Somaliland. The type of barriers leading to delayed performance of CS after a doctor's decision were also explored.

METHODS

Women were followed from the time of decision to perform CS until discharge from the hospital between 15 April 2019 and 30 March 2020. No delay was defined as < 1 hour and delayed CS was defined as 1-3 hours and >3 hours from decision of CS to delivery. Information was collected on barriers leading to delayed CS and maternal and newborn outcomes. Data was analysed using binary and multivariate logistic regression.

RESULTS

Overall, 1255 women were recruited from a larger cohort of 6658 women. A delay in CS >3 hours was associated with higher odds of severe maternal outcomes (aOR 1.58, 95% CI [1.13-2.21]). On the contrary, delay in performing a CS >3 hours was associated with lower odds of stillbirth (aOR 0.48, 95% CI [0.32-0.71]) compared to women without delay. Further, family decision-making for consent was the most important barrier leading to delays of >3 hours as compared to financial factors and barriers related to healthcare providers (48% vs 26% and 15%, respectively, p < 0.001).

CONCLUSIONS

In this setting, delay in performing CS >3 hours was associated with higher risk of severe maternal outcomes. A standardised system of performing a CS by primarily addressing the barriers associated with family decision-making, financial aspects and healthcare providers is needed.

Implementing maternal and newborn health quality of care standards in healthcare facilities to improve the adoption of respectful maternity care in Bangladesh, Ghana and Tanzania: a controlled before and after study

INTRODUCTION

Many women worldwide cannot access respectful maternity care (RMC). We assessed the effect of implementing maternal and newborn health (MNH) quality of care standards on RMC measures.

METHODS

We used a facility-based controlled before and after design in 43 healthcare facilities in Bangladesh, Ghana and Tanzania. Interviews with women and health workers and observations of labour and childbirth were used for data collection. We estimated difference-in-differences to compare changes in RMC measures over time between groups.

RESULTS

1827 women and 818 health workers were interviewed, and 1512 observations were performed. In Bangladesh, MNH quality of care standards reduced physical abuse (DiD -5.2;-9.0 to -1.4). The standards increased RMC training (DiD 59.0; 33.4 to 84.6) and the availability of policies and procedures for both addressing patient concerns (DiD 46.0; 4.7 to 87.4) and identifying/reporting abuse (DiD 45.9; 19.9 to 71.8). The control facilities showed greater improvements in communicating the delivery plan (DiD -33.8; -62.9 to -4.6). Other measures improved in both groups, except for satisfaction with hygiene. In Ghana, the intervention improved women's experiences. Providers allowed women to ask questions and express concerns (DiD 37.5; 5.9 to 69.0), considered concerns (DiD 14.9; 4.9 to 24.9), reduced verbal abuse (DiD -8.0; -12.1 to -3.8) and physical abuse (DiD -5.2; -11.4 to -0.9). More women reported they would choose the facility for another delivery (DiD 17.5; 5.5 to 29.4). In Tanzania, women in the intervention facilities reported improvements in privacy (DiD 24.2; 0.2 to 48.3). No other significant differences were observed due to improvements in both groups.

CONCLUSION

Institutionalising care standards and creating an enabling environment for quality MNH care is feasible in low and middle-income countries and may facilitate the adoption of RMC.

Strategies to improve interpersonal communication along the continuum of maternal and newborn care: A scoping review and narrative synthesis

Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns' families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns.

The Case for Using a Behavior Change Model to Design Interventions to Promote Respectful Maternal Care

Applying a behavior change framework to guide the design of interventions to improve respectful maternity care (RMC) could accelerate and unify the implementation and evaluation of diverse RMC interventions.

The Quality of Informed Consent in Caesarean Section at a Tertiary Hospital in Addis Ababa, Ethiopia

Purpose

The absence of high-quality and timely informed consent creates a barrier between the health-care provider and the patient that reinforces a negative view of the healthcare system, deters utilization of health-care services and increases malpractice lawsuits. This research aimed to assess the quality of informed consent in cesarean section (CS) at a large tertiary care center in Ethiopia.

Patients and Methods

An institutional cross-sectional study was conducted on 288 women who underwent planned or emergency CS. A structured questionnaire for respondents with standard indicators was developed as per the recommendations of the Royal College of Surgeons for the evaluation of the completeness of the informed consent document on the medical records.

Results

The median (IQR) age of the participants was 28 (25.0–32.0) years and 203 (70.5%) has undergone emergency CS. More than half of the respondents 172 (59.7%) were unaware of who would perform the surgery and only 50 (17.4%) of respondents stated they were informed of complications of the CS. A total of 157 (56.3%) of responses fulfilled the criteria for adequate subjective informed consent with an affirmative response while only 109 (37.9%) of responses fulfilled the criteria for adequate objective informed consent. Only educational status of the patient was associated with subjective adequacy of informed consent with those who have some formal education having 2.05 times odds of having adequate subjective consent as compared to those with no formal education.

Conclusion

In this study, we have found that women undergoing CS receive inadequate informed consent. This inadequate informed consent occurs across planned and emergency CS. The results highlight the need for better consent process to increase patient awareness and promote patient-centered-care.

A landscaping review of interventions to promote respectful maternal care in Africa: Opportunities to advance innovation and accountability

OBJECTIVE

In the past decade, global recognition of the need to address disrespect and abuse (also described as mistreatment of women) and promote respectful maternal care in facility-based childbirth has increased. While many studies have documented gaps in respectful maternal care, little is known about the design and implementation of these interventions. Our aim was to summarize and describe respectful maternal care -promoting interventions during childbirth implemented in Africa.

DESIGN

We identified respectful maternal care -promoting interventions in Africa through a rapid scoping of peer-reviewed articles and gray literature, and a crowdsourcing survey distributed through stakeholder networks.

SETTING

Africa PARTICIPANTS: NA MEASUREMENTS AND FINDINGS: We identified 43 unique interventions implemented in 16 African countries, gathered from a crowdsourcing survey, gray and published literature between 2010 and 2020. Most interventions were implemented in East Africa (N = 13). The interventions had various targets and were categorized into nine approaches, 60% of interventions focused on training providers about respectful maternal care and practice. About two thirds included multiple intervention approaches, and about two thirds addressed respectful maternal care beyond the period of childbirth. Few publications presented data on the effectiveness of the intervention, and those that did used a wide variety of indicators.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a reliance on provider training approaches to promote respectful maternal care and there are few examples of either engaging women in the community or adopting social accountability approaches. We encourage implementors to develop interventions targeting multiple approaches beyond provider training and consider delivery across pre-pregnancy, pregnancy, birth, and the postnatal periods. Finally, in order to effectively move from documenting respectful maternal care gaps to action and scale, we need global consensus on common indicators and measures of effectiveness for interventions promoting respectful care across the life course.

Health workers' perspectives on informed consent for caesarean section in Southern Malawi

Objective

Informed consent is a prerequisite for caesarean section, the commonest surgical procedure in low- and middle-income settings, but not always acquired to an appropriate extent. Exploring perceptions of health care workers may aid in improving clinical practice around informed consent. We aim to explore health workers’ beliefs and experiences related to principles and practice of informed consent.

Methods

Qualitative study conducted between January and June 2018 in a rural 150-bed mission hospital in Southern Malawi. Clinical observations, semi-structured interviews and a focus group discussion were used to collect data. Participants were 22 clincal officers, nurse-midwives and midwifery students involved in maternity care. Data were analysed to identify themes and construct an analytical framework.

Results

Definition and purpose of informed consent revolved around providing information, respecting women’s autonomy and achieving legal protection. Due to fear of blame and litigation, health workers preferred written consent. Written consent requires active participation by the consenting individual and was perceived to transfer liability to that person. A woman’s refusal to provide written informed consent may pose a dilemma for the health worker between doing good and respecting autonomy. To prevent such refusal, health workers said to only partially disclose surgical risks in order to minimize women's anxiety. Commonly perceived barriers to obtain a fully informed consent were labour pains, language barriers, women’s lack of education and their dependency on others to make decisions.

Conclusions

Health workers are familiar with the principles around informed consent and aware of its advantages, but fear of blame and litigation, partial disclosure of risks and barriers to communication hamper the process of obtaining informed consent. Findings can be used to develop interventions to improve the informed consent process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00584-9.