Sexual and Reproductive Health Services in Low- and Middle-Income Countries: Understanding the Role and Perspectives of Health Care Providers

Abstract

The last several decades have seen significant progress to promote and protect sexual and reproductive health (SRH) as a human right, yet targets set by the Millennium Development Goals to reduce maternal mortality by 75% in 2015 were largely unmet, and significant geographic disparities in sexual and reproductive health outcomes persist. One driver of poor SRH care and outcomes is poor performance of health care providers, who play an outsized role in determining patient outcomes, and must be competent, properly equipped, and motivated to provide high quality care. Yet health care providers in LMICs work in resource-constrained environments that make it challenging to consistently perform well in their roles. Improving our understanding of the perspectives of health care providers in LMICs, and the challenges they face, is a critical step to improving the quality of SRH services. In the three chapters that follow, I use mixed methods approaches to investigate provider-related issues in SRH care in LMIC. Each chapter addresses a different aspect of the SRH ecosystem. In my first study, I use a phenomenological qualitative study design with Jordanian health care providers to assess attitudes towards adolescent SRH, including their biases against adolescent sexual activity and contraceptive use, and their ideas for how youth-friendly services can be improved. We found high levels of stigma and shame around premarital sex, yet providers recognized the need to engage youth in conversations that are otherwise considered taboo, in particular to ensure healthy timing and spacing of future pregnancies. The findings highlight the need for a national prioritization of youth-friendly SRH services, including investment in provider behavior change to eliminate provider biases as a key driver of poor SRH services for adolescents. In my second study, I leverage a unique dataset combining primary data collection with providers and clinical observations of childbirth to estimate the role of provider personality traits and their association with respectful maternity care during childbirth in Kenya. We found variation by provider in level of respectful care, but ultimately found no association between personality and disrespect and abuse. These findings highlight the need for further research to parse out the driving factors behind individual provider variation in respectful maternity care. In my third study, I use a case series and phenomenological qualitative study design with health care providers at primary care facilities in Kenya to understand the challenges they face in the management of postpartum hemorrhage and the coordination of patient referrals to higher-level care. We found significant challenges in managing PPH due to provider-related factors as well as structural and health system challenges. We found that referral processes were hindered by slow decision-making by providers, poor relationships between different facilities, structural barriers such as transport and supply shortages, as well as patient resistance to referral due to transport costs. These findings confirmed several well-known challenges at the primary care level in managing obstetric emergencies, including significant underperformance by providers. In addition, the findings highlight the presence of poor working relationships across referral networks that further delays patients from receiving adequate care. Health care providers play a critical role in delivering quality SRH care to patients. The three papers in this dissertation underscore the importance of understanding provider roles and perspectives contributions both as individuals and as a group with shared experiences. The findings highlight some of the issues that providers face in fulfilling their roles and the potential impact that those challenges have on the quality of care and therefore patient outcomes. To address these challenges, solutions must be designed and tested to be responsive to the needs of patients and providers alike, in the context of an enabling environment.