Base y Oferta Monetaria

Finally I examined the literature regarding the analysis of healthcare providers behaviour in other settings, the root causes and contributing factors of

suboptimal care.

South African health workers said that: the length of the waiting queue, if they had been up at night with a birth, and how supportive the doctors were affected the care that they gave (Fonn and Xaba 2001). They explained that a lack of positive role models discouraged them from working to a high standard, and that they took out their frustrations with their supervisors on women. As they reflected on their professional training, health workers explained that it had been ‘Eurocentric,’ and did not take into account the social setting of women.

The health workers said that they had been discouraged from asking questions and as a result they were intolerant of women who asked them questions. Chokwe and Wright (2011) conducted a phenomenological study investigating the experiences and perspectives of clinical care by learner midwives in South Africa. The authors concluded that if uncaring behaviours are modelled it is difficult for learner midwives to internalize caring and make it part of their daily practice.

Although the study by Jewkes and colleagues (1998) could be considered ‘old’ it is valuable for its broad analysis of abuse. In addition to the perspectives of nurses/midwives and the women accessing South African maternity services, other contextual factors are explored including the impact of professional training on identity and nurse-patient relationships, the influence of social context and the recent history of apartheid on the behaviour of staff. Jewkes and colleagues found that public health services were characterised by conflict, clinical neglect, verbal and physical abuse. The nursing staff were insecure performing their clinical roles, they lacked support in an environment with poor clinical outcomes and felt they were unfairly blamed when problems arose. In addition, there was an underpinning ideology of patient inferiority. Nurses perceived themselves as victims of abuse from the patients and used these perceptions to justify their actions in trying to exert “control” over the

environment.

Mohammad-Alizadeh et al. (2009) explored the views of Iranian health

providers on primary reproductive health services to understand and address the barriers to high-quality services. Focus group discussions with midwives and with other family health providers were used to explore staff roles, supervision, in-service education and ideas for increasing standards of care. Working with clients was the most satisfying part of their duties but many

organisational factors beyond their control caused frustration and dissatisfaction (Mohammad-Alizadeh et al. 2009). Health providers explained that duties were not assigned according to their individual education and competencies. The midwives, including one with a BSc degree, complained that they were

becoming de-skilled because of the other tasks they had to perform. They estimated that 60% of their time was spent in record writing due to inefficiencies in patient record systems; as a result they said the clients were neglected. Health providers felt unsupported and unvalued by managers who highlighted the negative aspects of their work without considering the underlying causes. “Above all,” Mohammad-Alizadeh et al. (2009, p.726) concluded, “the findings indicate a strong need for individual staff members to feel valued, supported and to develop their roles”. This study was of particular interest because of cultural similarities between Iran and Afghanistan. In Afghanistan, such a wide mix of ages and educational backgrounds in focus group participants (from 26 - 51 years and four years of university education to none) could result in the most senior member of the group being the dominant contributor and opinion leader, suppressing other opinions. This may also have resulted in possible bias in the Iranian study.

A mixed methods study by Hassan-Bitar and Narrainen (2011) explored the challenges and barriers that maternal healthcare providers faced in the Occupied Palestinian Territory. In a difficult and resource-constrained

environment midwives were at the bottom of the professional hierarchy. They wanted respect and an acknowledgement of their important role but were stressed by an “insane” workload, the lack of supplies, and a lack of

professional support or guidance (Hassan-Bitar and Narrainen 2011, p.155). Midwives and nurses reported that they were humiliated because managers and doctors shouted at them in public. They also faced the frustration of

women’s families over the lack of resources, lack of beds or the absence of the doctor. Supervision focused on mistakes, gaps in work and punishment. Staff evaluations were given without explanation or the chance to improve. The need for supportive rather than punitive supervision was also important to healthcare providers in Tanzania (Manongi et al. 2006). One assistant clinical officer explained that “supervision is not kindly and lovingly done”, instead people come with… paper and pens… “asking questions like a policeman” (Manongi et al. 2006, p.5). The lack of transparency and fairness in promotions and salary increases demotivated staff.

Much of the literature on healthcare providers came from the human resources and motivation perspective (Fort and Voltero 2004; Dieleman et al. 2006; Willis- Shattuck et al. 2008). It clarified that the motivation of individuals, “their

willingness to exert and maintain an effort towards organisational goals” (Franco et al. 2002, p.1255) has a direct impact on the quality, efficiency and equity of health services (Franco et al. 2004). Although motivation was not the focus of this study per se, Franco and colleagues stated that poor motivation can show itself in a lack of courtesy to patients, a lack of attention to procedures, such as examining patients correctly, or the failure to treat patients in a timely manner.

As part of their review into disrespect and abuse in facility based childbirth, Bowser and Hill (2010) noted many contributing factors such as provider prejudice based on race, ethnicity, age, financial and educational status. Professional training distanced providers from the women in their care; under- resourced health systems, understaffing, and lack of professional development opportunities were seen to affect provider motivation. The authors highlighted gaps in the evidence around respectful care including the lack of validated tools to measure the prevalence of disrespect, the need to analyse contributing factors and the need to study the impact of disrespect and abuse on the utilisation of skilled birth care. Although “the analysis of contributing factors” could include the perspective of healthcare providers, the predominant

emphasis was on the measurement and impact of abuse, rather than in-depth analysis and understanding of context.

D’Ambruoso and colleagues (2005, p.9) emphasised that, in addition to the views of women, it was important to examine the perspectives of providers as “two parts of the whole”. My review of the literature indicated that there has been less examination or analysis of the perspectives of healthcare providers globally, compared to the experiences and perspectives of perinatal women. As the authors of a report from the CHANGE programme on assessing the caring behaviours of healthcare providers stated:

“Less emphasis has been placed on the views of maternal care providers perhaps because it is assumed that there is a universal provider point of view on the importance of caring as well as curing” (Moore et al. 2002, p.3).

The insights into the roots of staff behaviour highlighted a number of common issues including the need for respect, constructive supervision and support. In each context there were also unique constraints, frustrations and contributing factors. For example, Palestinian midwives and nurses were stressed,

managing their own frustrations at the overwhelming workload and lack of supplies, as well as the frustrations of women’s families; black nurses in South Africa affected by the legacy of apartheid struggled to assert their identity and power over women in childbirth; midwives in Iran were becoming deskilled because they were required to perform many non-midwifery tasks and roles. It was likely that the Afghan healthcare providers would also have their own unique challenges and perspectives that affected their care of childbearing women.

Following my initial literature review I refined the research questions that would guide my study.