In many health facilities around the world, people giving birth can walk into different realities. There’s the experience of people who have connections or who belong to the right group. Then there’s the experience of those walking into an unfamiliar place, lacking resources or stature. These disparities hit home for Dr. Patience Afulani, Assistant Professor in the Department of Epidemiology & Biostatistics, when she reflected on her experiences giving birth in Ghana, in a hospital where she worked as a doctor, and in a US hospital as a graduate student. Knowing that not every woman who walked in the door would be given the same respect and attention inspired her to devote her work to understanding and improving the quality of maternal health care.
Dr. Afulani has always been close to medicine; she grew up in a semi-detached house in Ghana with a private clinic in the other half. She was often in there, and also in the regional hospital, and was fascinated by what the doctors were doing. Though she never saw a female doctor there, she excelled in science and knew she wanted to become a physician. Working as a medical doctor in a hospital in Ghana helped spark her interest in maternal and child health and how they’re impacted by women’s experiences.
There was a lot of talk in global health efforts about getting women to turn up to health facilities. But not nearly as much attention on what happened once they got there—particularly related to how responsive and respectful the care is. “I think women’s experience is really undervalued but plays a very important role,” Dr. Afulani says. “Medical training is very technical. There’s a lot of focus on the technical aspects of care and less on the interpersonal aspects, which is the vehicle by which care is delivered.”
Almost all of the research on women’s experiences prior to 2017 was based on qualitative interviews with women. Those insights are valuable and help convey the pain and frustration that women face when they are not treated with respect. Dr. Afulani was struck by the extent of disrespect and abuse, poor communication, and lack of autonomy that surfaces in those stories; she heard stories of women being sent for c-sections with no explanation for why. Such negative experiences can deter women from seeking care in healthcare facilities. In some cases, they share their harrowing stories with friends and neighbors, also deterring them from seeking care in those facilities and thus endangering progress on maternal and child health.
But qualitative research alone makes it hard to tackle the problem on a global scale, and satisfaction measures leave a lot out of the picture. “Women’s experiences are complex,” says Dr. Afulani. “Women can report poor care and still say they’re satisfied, so it’s not really useful.” So Dr. Afulani set out to create a new tool to quantify just what was happening in those personal interactions and how it influences people’s health.
Dr. Afulani’s Person-Centered Maternity Care scale provides an answer for people who want to see numbers to explain the phenomenon of poor experience in maternity care. Without a tool like this, everyone is measuring the problem in a different way. It’s hard to know how women’s experiences in Ghana compare to those in Kenya. The scale adds a solid foundation for understanding whether care is actually improving over time. And it will help evaluate proposed solutions to see if they’re actually the best way to solve the problem. Dr. Afulani is at the forefront of this essential work—her tool is one of only two tools that have been validated in low-resource settings and is being used in at least ten countries.
The next step for Dr. Afulani is testing some of those possible solutions. Her research has identified unconscious bias and stress among providers as major drivers of disrespectful care. Many of these providers are trying to do their best in challenging circumstances and don’t recognize the scale of mistreatment. She’s already seen some promising results partnering with PRONTO International, showing that integrating concepts of interpersonal care into their obstetric simulation training led to better experiences. Dr. Afulani is just getting started with using her invaluable tool to measure much-needed progress so that women feel heard and valued during their healthcare encounters. “I want to see a world where every woman can have a good healthcare experience, regardless of who they are, who they know, or where they go.”
First published by the Bixby Center.