Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya

A quasi-experimental design will be followed with surveys at twelve health facilities in four districts and one large maternity hospital in Nairobi and areas before and after the introduction of disrespect and abuse (D&A) interventions. The design is aimed to control for potential time dependent confounding on observed factors.This study seeks to conduct implementation research aimed at designing, testing, and evaluating an approach to significantly reduce disrespectful and abusive (D&A) care of women during labor and delivery in facilities. Specifically the proposed study aims to: (i) determine the manifestations, types and prevalence of D&A in childbirth (ii) develop and validate tools for assessing D&A (iii) identify and explore the potential drivers of D&A (iv) design, implement, monitor and evaluate the impact of one or more interventions to reduce D&A and (v) document and assess the dynamics of implementing interventions to reduce D&A and generate lessons for replication at scale.Pregnancy, childbirth, and their consequences are still the leading causes of death, disease and disability among women of reproductive age in developing countries. Maternal mortality is highest in Sub-Saharan Africa, where the maternal mortality ratio (MMR) is one hundred times greater than in developed regions [1]. One key strategy to address high maternal and newborn morbidity and mortality is to increase the proportion of births attended by skilled birth attendants (SBA); indeed, this is an indicator for United Nations Millennium Development Goal (MDG) 5. Progress has been slow towards achieving this MDG indicator [1] because improvements require overcoming financial and geographic barriers to accessing SBA, as well as poor quality of care at facilities [1,2].An important, but little understood component of the poor quality of care experienced by women during childbirth in facilities is disrespectful and abusive behavior by health workers and other facility staff [3]. Bowser and H