What is quality in maternal and neonatal health care?

Objective

to review published papers and reports examining quality of care in maternal and newborn health to identify definitions and models of quality of care.

Design

literature review.

Search strategy

electronic search of MEDLINE and organisational databases for literature describing definitions and models of quality used in health care and maternal and newborn health care. Relevant papers and reports were reviewed and summarised.

Findings

there is no universally accepted definition of quality of care. The multi-faceted nature of quality is widely acknowledged. In the literature quality of care is described: from the perspective of health care providers, managers and patients; dimensions within the health care system; using elements such as safety, effectiveness, patient-centeredness, timeliness, equity and efficiency; and through the provision of care and experience of care.

Key conclusions

the importance of ensuring good quality of care for women and newborn babies is well recognised in the literature, however, there is currently no agreed single and comprehensive definition described. Several models were identified, which can be combined to form a comprehensive framework to help define and assess quality of care or lack of quality. Approaches to quality of care that are specifically important for maternal and newborn health were identified and include a rights based approach, adopting care that is evidence-based, consideration of the mother and baby as interdependent and the fact that pregnancy is on the whole a healthy state.

Implications for practice

a model of quality of maternal and newborn health care using perspectives, characteristics, dimensions of the system and elements of quality of care specific to maternal and newborn health is proposed, which can be used as a basis for developing quality improvement strategies and activities, and incorporating quality into existing programmes.     

The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon

Objective

to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes.

Design

a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health.

Setting

childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon.

Participants

in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected.

Measurements

the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008.

Findings

the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries.

Key conclusions and implications for practice

there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.     

The role of faith-based organizations in maternal and newborn health care in Africa

Background

Global disparities in maternal and newborn health represent one of the starkest health inequities of our times. Faith-based organizations (FBOs) have historically played an important role in providing maternal/newborn health services in African countries. However, the contribution of FBOs in service delivery is insufficiently recognized and mapped.

Objectives

A systematic review of the literature to assess available evidence on the role of FBOs in the area of maternal/newborn health care in Africa.

Search strategy

MEDLINE and EMBASE were searched for articles published between 1989 and 2009 on maternal/newborn health and FBOs in Africa.

Results

Six articles met the criteria for inclusion. These articles provided information on 6 different African countries. Maternal/newborn health services provided by FBOs were similar to those offered by governments, but the quality of care received and the satisfaction were reported to be better.

Conclusion

Efforts to document and analyze the contribution of FBOs in maternal/newborn health are necessary to increase the recognition of FBOs and to establish stronger partnerships with them in Africa as an untapped route to achieving Millennium Development Goals 4 and 5.     

Delivering maternal health care services in an internal conflict setting in Maguindanao, Philippines

To improve access to maternal health care and family planning services in conflict-stricken Maguindanao province, southern Philippines, several non-governmental organisations have begun collaborating with local public health services. This exploratory study describes the experiences of local government service providers and two NGOs in a context of long-standing internal armed conflict, how and to what extent provision has been affected by the conflict and what has been done to overcome its effects. It is based on interviews with six health service coordinators and providers. Local government-NGO partnership takes the form of giving NGOs space in government health care facilities and receiving from them critical supplies, personnel and contraceptives. Service delivery structures have generally been spared from direct attacks by the parties involved locally in armed conflict due to the perceived benefits of their services, including for rebels and their families, their neutral stance and willingness to treat everyone. However, they do suffer from occasional disruption and kidnappings and need to seek protection from local leaders. When mass evacuation is required providers follow displaced families to evacuation points to ensure they continue to get services. Collaboration for maternal health care provision is recent, but the planned expansion of NGO projects will help it to evolve.     

Advancing newborn health and survival in developing countries: a conceptual framework.

Four million newborns die every year at home, often without skilled care at delivery or any other contact with the formal health system. Improved household practices and use of services, often in the community, should improve survival. We developed a conceptual framework for household and community newborn and maternal care that acknowledges the inseparability of the mother and neonate, yet stresses elements relating to the newborn, heretofore underemphasized in safe motherhood and child-survival programs. The framework identifies five paths that, if implemented well, would generally improve newborn outcomes: (1) use of routine maternal and newborn care and good-quality services; (2) response to maternal danger signs; (3) response to the nonbreathing newborn; (4) care for the low birth weight baby; and (5) response to newborn danger signs, particularly those of infection. This model, balancing preventive (19 routine behaviors) and curative care (14 special behaviors), is rooted in the community, bridges safe motherhood and child survival, and provides a framework for newborn health research, programmatic, and advocacy agendas for developing countries.     

Utilizing Task Shifting to Increase Access to Maternal and Infant Health Interventions: A Case Study of Midwives for Haiti

The shortage of health workers worldwide has been identified as a barrier to achieving targeted health goals. Task shifting has been recommended by the World Health Organization to increase access to trained and skilled birth attendants. One example of task shifting is the use of cadres of health care workers, such as nurses and auxiliary nurse‐midwives, who can successfully deliver skilled care to women and infants in low‐resource areas where women would otherwise lack access to critical health interventions during the childbearing years. Midwives for Haiti is an organization demonstrating the use of task shifting in its education program for auxiliary midwives. Graduates of the Midwives for Haiti education program are employed and working with women in hospitals, birth centers, and clinics across Haiti. This article reviews the Midwives for Haiti education program and presents successes and challenges in task shifting as a strategy to increase access to skilled maternal and newborn care and to meet international health goals to reduce maternal and infant mortality in a low‐resource country.     

Approaches to improve Quality of Care (QoC) for women and newborns: conclusions,evidence gaps and research priorities

This series of papers focuses on a quality of care framework for maternal health, and systematically reviews the evidence of interventions aimed at improving care at the community-, district- and factility-levels. While the systematic reviews highlight the effectiveness of specific quality improvement efforts on maternal and newborn health, it also illlustrates the dearth of evidence on community-, district- and facility-level interventions, particulary for issues specific to quality of maternal health care and maternal newborn health outcomes. Further evidence is now needed to evaluate the best possible combination of the strategies. Governments, stakeholders and donors need to work together to form these policies and develop models of health care to suit the needs of their own population.     

Community-driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India

ObjectiveTo assess the effect on maternal health outcomes of a community-based behavior change management intervention for essential newborn care leading to a reduction in neonatal mortality.MethodsA cluster-randomized controlled trial involving 1 control and 2 intervention arms was conducted in Shivgarh, India, between January 2004 and May 2005. Risk-enhancing domiciliary newborn care behaviors, including those posing a concomitant risk to maternal health, were targeted through home visits and community meetings. Secondary outcomes included knowledge of maternal danger signs, self-reported complications, maternal care practices, care-seeking from trained providers, and maternal mortality ratio (MMR). The intervention arms were combined for analysis, which was done by intention to treat.ResultsSignificant improvements were observed in maternal health equity and outcomes including knowledge of danger signs, care practices, self-reported complications, and timely care-seeking from trained providers. The difference in adjusted MMR was not significant (relative risk 0.44; 95% confidence interval, 0.14–1.43; P = 0.11) owing to the inadequate sample size for this outcome, but may suggest a decline in MMR given improvements in other outcomes in the causal pathway to mortality.ConclusionCommunity-based strategies focused on prevention and care-seeking effectively complemented facility-based strategies toward improving maternal health, while synergizing with newborn care interventions.     

Experiences with facility-based maternal death reviews in northern Nigeria

Objective

To evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and newborn health care in northern Nigeria.

Methods

A combination of quantitative and qualitative methods was used, including review of MDR forms and of health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees.

Results

Facility-based MDRs were initiated in 75 emergency obstetric and newborn care facilities in northern Nigeria and were initially conducted in the 33 hospitals; however, the process stopped after some time and had to be revitalized. Main reasons were transfer of key members of MDR committees, lack of supportive supervision, and shortage of staff. Ninety-three (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. MDRs resulted in improved quality of care, including mobilization of additional resources. Challenges were fear of blame, shortage of staff, transfer of MDR team members, inadequate supportive supervision, and poor record keeping.

Conclusion

MDR requires teamwork, commitment, and champions at health facility level to spearhead the process. MDR needs to be institutionalized in the Ministry of Health, which provides oversight, policy guidance, and support, including supportive supervision.     

Postpartum Care of the Mother and Newborn: A Practical Guide

This paper defines the needs of women and their newborns, and classifies a number of practices common in postpartum care. It is a summary of the report, Postpartum Care of the Mother and Newborn: A Practical Guide, which was developed by a Technical Working Group of the World Health Organization and published in 1998. The report takes a comprehensive view of maternal and newborn needs during the postpartum period, examining major maternal and neonatal health challenges, nutrition and breastfeeding, birth spacing, immunization, HIV/AIDS, and the essential elements of care and service provision. The document lists recommendations, and classifies common practices in the postpartum period, dividing them into four categories: those which are useful, those which are harmful, those for which insufficient evidence exists, and those which are frequently used inappropriately.     

Disease burden due to pre-eclampsia/eclampsia and the Ethiopian health system's response

Objective

To assess the maternal disease burden due to pre-eclampsia/eclampsia in Ethiopia and the national health system's readiness to respond to the needs of women with pre-eclampsia/eclampsia.

Methods

The national emergency obstetric and newborn care (EmONC) assessment entailed collecting information from 112 hospitals and 685 health centers in Ethiopia, focusing on their infrastructure, the services they provided, human resources, equipment and supplies, case load, and mortality due to pre-eclampsia/eclampsia.

Results

Pre-eclampsia/eclampsia complicated 1.2% of all institutional deliveries. Given the low institutional delivery rate and an expected incidence of 2%-8% of all deliveries, this implies that only a small fraction (3.8%) of all women with pre-eclampsia/eclampsia received care at health facilities. 11% of all maternal deaths and 16% of direct maternal deaths were due to this obstetric complication. The cause-specific case fatality rate was high (3.6%). Availability of urine test strips, anticonvulsants, antihypertensives, and actual service provision to treat these diseases was limited, especially at health centers.

Conclusion

The salutary effects of the national EmONC assessment were immediate, as evidenced by how quickly the release of the Ethiopian report led to important national efforts to improve maternal and newborn health. Expansion of health services should be augmented with periodic assessments of logistics and quality-related issues to assure functioning facilities for women accessing obstetric services.     

Privatisation of health services and the reproductive health of rural Chinese women

China’s rural health care system has undergone major changes since the early 1980s, when the country began privatising rural health services. Following fiscal devolution, the rural primary health service was transformed into a fee-for-service system, dependent on the availability of local resources. This article reports some of the results of a study undertaken in 1994–96 to examine the impact of privatization on financing, provision and use of reproductive health services by women in two rural counties in Yunnan Province, China. The most common self-reported symptoms of reproductive morbidity were abnormal vaginal discharge and vaginal tears during home delivery, which went mostly untreated. Hospital-based delivery and use of antenatal care was very low, adversely affected by costs and perceived low quality. Service quality was affected by low investment in training, maintenance and supervision of workers. Most of the burden for maternal and child health care fell on local health workers, yet resources for these services had declined from 1985 to 1995. Only support for family planning services, which were funded and provided separately, had increased. Rural women’s reproductive health needs were inadequately attended to by rural health services following reforms. Our data has helped to increase attention to those needs within planned reform efforts.     

探索如何提高妇幼保健护理工作医护人员的素养

目的:探索如何提高妇幼保健护理工作医护人员的素养。方法:从目前妇幼保健护理工作的状况入手,结合当今妇幼保健护理护理工作的特性进行理性分析。结果:随着现代人的健康观念的转变以及理疗设备、医疗技术的改进,妇幼保健的内容以及服务形式已将产生了极大的变化。医护人员已经开始走出医疗机构,已延伸到社区的保健预防工作,同时对医护人员的的要求也相对高了许多。结论:加强对基层妇保工作人员的培训,引进专业人才,提高妇保工作人员的整体素质,政府应当加大对基层妇幼保健工作的扶持力度。     

Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis

Background

Maternal and newborn health care intervention coverage has increased in many low-income countries over the last decade, yet poor quality of care remains a challenge, limiting health gains. The World Health Organization envisions community engagement as a critical component of health care delivery systems to ensure quality services, responsive to community needs. Aligned with this, a Participatory Community Quality Improvement (PCQI) strategy was introduced in Ethiopia, in 14 of 91 rural woredas (districts) where the Last Ten Kilometers Project (L10 K) Platform activities were supporting national Basic Emergency Obstetric and Newborn Care (BEmONC) strengthening strategies. This paper examines the effects of the PCQI strategy in improving maternal and newborn care behaviors, and providers’ and households’ practices.

Methods

PCQI engages communities in identifying barriers to access and quality of services, and developing, implementing and monitoring solutions. Thirty-four intervention kebeles (communities), which included the L10 K Platform, BEmONC, and PCQI, and 82 comparison kebeles, which included the L10 K Platform and BEmONC, were visited in December 2010–January 2011 and again 48 months later. Twelve women with children aged 0 to 11 months were interviewed in each kebele. Propensity score matching was used to estimate the program’s average treatment effects (ATEs) on women’s care seeking behavior, providers’ service provision behavior and households’ newborn care practices.

Results

The ATEs of PCQI were statistically significant (p?<?0.05) for two care seeking behaviors — four or more antenatal care (ANC) visits and institutional deliveries at 14% (95% CI: 6, 21) and 11% (95% CI: 4, 17), respectively — and one service provision behavior — complete ANC at 17% (95% CI: 11, 24). We found no evidence of an effect on remaining outcomes relating to household newborn care practices, and postnatal care performed by the provider.

Conclusions

National BEmONC strengthening and government initiatives to improve access and quality of maternal and newborn health services, together with L10 K Platform activities, appeared to work better for some care practices where communities were engaged in the PCQI strategy. Additional research with more robust measure of impact and cost-effectiveness analysis would be useful to establish effectiveness for a wider set of outcomes.

     

Perceptions of women on workloads in health facilities and its effect on maternal health care: A multi-site qualitative study in Nigeria

Objectiveof the study was to explore women's perception of maternal health care providers’ workload and its effects on the delivery of maternal healthcare in secondary and tertiary hospitals in Nigeria.Research Design, setting, participantsfive focus groups discussions (FGDs) were conducted with women in each of eight secondary and tertiary hospitals in 8 States in four geo-political zones of the country. In all, 40 FGDs were held with women attending antenatal and post-natal clinics in the hospitals. We elicited information on women's perceptions of workloads of maternal health providers and the effects of the workloads on maternity care. The discussions were audio-taped and transcribed while thematic analysis was carried out using Atlas.ti computer software.Findingsthe majority of the participants submitted that the health providers are burdened with heavy workloads in the provision of maternal health care. Examples of heavy workload cited included complaints from health providers, evidence of stress and strain in care provision by providers and the sheer numbers of patients that are left unattended to in health facilities. Poor quality care, insufficient time to carry out necessary investigations on patients, and prolonged waiting time experienced by women in accessing care featured as consequences of heavy workload, with the secondary result that women are reluctant to seek care in the health facilities because of the belief that they would spend a long time in receiving care.Key conclusions and implications for practicewe conclude that women are concerned about heavy workloads experienced by healthcare providers and may partly account for the low utilization of referral health facilities for maternal health care in Nigeria. Efforts to address this problem should include purposeful human resource policy development, the development of incentives for health providers, and the proper re-organization of the health system.