We will apply a design based on mixed methods, both qualitative and quantitative. This will be survey tools as well as interviews and semi-participatory methods. This project additionally aims to develop a tool for measuring the interpersonal quality of care in this context. This will then be used as a tool to measure the effect of the community participatory intervention on increasing quality of care.
The quality of care provided and in particular the interpersonal component of quality of care during pregnancy and childbirth should ensure that women are treated with ‘dignity’. The theoretical approach to this project therefore is grounded in an evaluation of dignity in health. Where the concept of dignity has universally been acknowledged to be a fundamental principle of human rights, critics claim that the vagueness of the term hinders effectuation of its implementation (Jacobson, 2007). Jacobsen argues this vagueness is largely attributed to lack of distinguishing ‘human dignity’ from ‘social dignity’(Jacobson, 2007).
Where human dignity refers to a person’s ability to make moral choices (Gennip, Pasman, Oosterveld-vlug, Willems, & Onwuteaka-philipsen, 2013; Jacobson, 2009; Leget, 2012), social dignity refers to a person’s position in society and social interactions with others (Jacobson, 2007; Leget, 2012). Following this distinction, it can be argued that the sense of dignity is susceptible to internal and external actions (Mann et al., 1994). Within healthcare dignity as a concept has mainly grown in the field of end-of-life care, palliative care and elderly care (Gennip et al., 2013; Jacobson, 2009).
Within maternal health, dignity as a human rights principle developed most fully within the context of family planning services but within a clinical setting is applicable to any human interaction in health facilities (L. Freedman, 2001). For this project we will evaluate the concept of quality of care, and in particular the interpersonal quality of care, against the conceptual elements of dignity as described by Jacobsen (2009). From this perspective dignity within human interactions can be violated or promoted through a number of social processes and under certain conditions (Jacobson, 2009).
To increase our knowledge of how perceptions of quality influence care seeking the concept of dignity is evaluated within the interactions that take place between the health provider and the pregnant women, their families and the community with the notion of the underlying power relations, the institutional setting and the broader social order that influence this interaction.
The project will make use of participatory approaches through the existing community groups to understand local knowledge and realities and to include communities in planning and implementation of the activities, which will increase the potential for ownership and sustainability. Community groups have been formed by the Woman Centered Care Project where groups are facilitated through a process of identifying problems related to pregnancy and childbirth, design strategies to solve priority problems identified, implement chosen strategies and evaluate them. Rather than designing interventions for the communities with regards to improving the quality of care this approach allows community groups to plan and implement their own strategies in close collaboration with community leaders. Jointly we will evaluate both the process and outcome of their interventions.
Although quantitative clinical research methods are used to assess care seeking and measurable indicators for quality of care, a social science approach will be used to understand the underlying factors contributing to care seeking through in-depth interviews and focus group discussions. Additionally the researcher will make use of participant observation while working in maternity wards in Tanzania with the aim to understand the behavior of health workers. By doing this out of the research setting it is hoped that it will not be of influence the data.