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Addressing Disrespect and Abuse in Kenya

Photo of Kenyan woman carrying water, Photoshare

Research Overview

An award was made to Population Council in February 2011 to fund implementation research on disrespect and abuse during facility-based childbirth in Kenya. The purpose of the research was to document the manifestations and prevalence of disrespect and abuse in facilities and to design, test and evaluate an approach for reducing the problem. The research aimed to promote respectful maternal care (the converse of disrespectful and abusive care) so demand for skilled delivery care increases and the quality of services rendered improves.



Project Location

Kenya: Nyanza, Nairobi, Central, and Rift Valley provinces

Research Objectives

The objectives of the study are as follows:

  • Develop and validate tools for assessing disrespect and abuse
  • Determine the manifestations, types, and prevalence of disrespect and abuse during childbirth
  • Identify and explore the potential drivers of disrespect and abuse
  • Design, implement, monitor and evaluate the impact of one or more interventions to reduce disrespect and abuse
  • Document and assess the dynamics of implementing interventions to reduce disrespect and abuse and generate lessons for replication

Study design and methods:

This study is embedded in Population Council's RH (Reproductive Health) Vouchers Project funded by the Bill and Melinda Gates Foundation. For information on the RH Vouchers Project, click here.

At the start of the project, the team met in Dar es Salaam, Tanzania to harmonize the project’s objectives, core indicators, and research methodologies along with developing common definitions of disrespect and abuse.

  • Validation of measurement instruments:

In order to validate the tools to measure disrespect and abuse, the team developed a Construct Map to identify the measurable elements of disrespect and abuse and conducted a number of qualitative interviews with clients to identify potential gaps in the Construct Map.

They used client exit tool to measure the prevalence of disrespect and abuse. In order to check the reliability of the exit tool in estimating the prevalence of disrespect and abuse, they conducted exit interviews as well as follow-up in-depth case narratives.

  • Health providers were interviewed using a questionnaire which covered questions on their knowledge, attitudes, practice and experiences of working in the maternity units.
  • Client provider interactions (CPIs) observations were conducted to provide data on observable actions or behaviors and actions that women themselves experience as disrespectful or abusive.
  • Client exit interviews (CEI) were carried out for women leaving the maternity units to capture the prevalence of disrespect and abuse.
  • The team conducted facility inventories and ran an assessment of record reviews for maternity inpatients to assess the standards of care in the facilities.
  • In-depth interviews with the senior health managers were performed to collect additional information on system level and governance factors that may contribute to abuse and disrespect.
  • Case narratives were conducted with the women who had suffered disrespect and abuse  two weeks after the client exit interviews (CEI) were completed. The case narratives provided a detailed assessment of the disrespect and abuse reported during the CEI.
  • In addition to all the above, focus group discussions (FGDs) were performed which explored and clarified views, opinions and perceptions and enhanced the findings from client exit surveys and other components of the study.


Heshima Theory of Change

Implementation activities addressed drivers identified at baseline and linked to measurement and expected outcomes as indicated in figure below.


Additional information and resources can be found on the Population Council research project page here.


Lessons Learned

  • Future work needs to focus on understanding the dynamics between communities and their facilities while dealing with disrespect and abuse.

  • Mediation, while a good idea, requires more development. Communities are happy to report problems but are not willing to be witnesses in mediation processes: They don’t want to meet the providers for fear of retribution or neglect should they need health care in the future. Some facility management staff did not warm to meeting with community members. 

  • Pre-service training needs to incorporate RMC. In many countries providers ‘learn’ their health service culture, which can be seen as encouraging disrespectful care. Students identify with role models.

  • Policy makers must be effectively engaged in governance and accountability for RMC within the health system, along with the recognition that it takes time to ensure more effective stewardship.

  • The participatory, continual, and reflective approach has ensured RMC is now embedded in the system, incorporated by MoH at national and county levels, evinced by the range of requests for support to scale up in Kenya, along with requests from other countries and interest from the technical working group, a subset of the international RMC TWG.

  • Continuous advocacy must be maintained for the universal rights of childbearing women in all MNH programs.

  • Respectful maternal care must be incorporated in WHO’s quality of care framework currently under discussion for finalization. Countries are more likely to accept the issue of disrespect and abuse and do something about it if direction comes from WHO.

  • Investment must be made in approaches that will improve provider motivation, self-worth, and empowerment opportunities for counseling and support, such as psychological debriefing: VCAT—values reflection—is one of the most important components to start the change process. Valued, motivated, and empowered providers (for making decisions), gives providers autonomy and respect for themselves.

  • Further work must ensure professional association support for the RMC agenda.


Dissemination of Findings




The emerging topic of disrespect and abuse during childbirth continues to grow as researchers develop new, more robust methods to measure the prevalence of disrespect and abuse, as well as plan, implement, monitor and evaluate interventions to reduce disrespect and abuse and promote respectful maternal care. Several of the TRAction Project’s implementation partners have recently published journal articles on this topic. Click on the links below to read more.

Exploring the Prevalence of Disrespect and Abuse during Childbirth in Kenya

by Timothy Abuya, Charlotte E. Warren, Nora Miller, Rebecca Njuki, Charity Ndwiga, Alice Maranga, Faith Mbehero, Anne Njeru, Ben Bellows. Published in PLOS One, April 2015.

The Effect of a Multi-Component Intervention on Disrespect and Abuse during Childbirth in Kenya

by Timothy Abuya, Charity Ndwiga, Julie Ritter, Lucy Kanya, Ben Bellows, Nancy Binkin, and Charlotte E. Warren. Published in BMC Pregnancy and Childbirth, 2015.

Study Protocol for Promoting Respectful Maternity Care Initiative to Assess, Measure and Design Interventions to Reduce Disrespect and Abuse during Childbirth in Kenya

by Charlotte Warren, Rebecca Njuki, Timothy Abuya, Charity Ndwiga, Grace Maingi, Jane Serwanga, Faith Mbehero, Louisa Muteti, Anne Njeru, Joseph Karanja, Joyce Olenja, Lucy Gitonga, Chris Rakuom and Ben Bellows. Published in BMC Pregnancy and Childbirth, 2013.


Research Partners


Heshima I

Federation of Women Lawyers (FIDA)

Kenya Ministry of Health

National Nurses Association of Kenya (NNAK)


Heshima II

Kenya Ministry of Health

Maternal and Child Survival Program (MCSP)

Migori County Health Management Team

Reproductive and Maternal Health Services Unit (RMHSU)


Principal Investigator: Charlotte Warren, Population Council


Project Status


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