‘The question should not be why do women not accept the service we offer, but why do we not offer a service that women will accept.’
Mahmoud Fathalla, 1998 Egypt
The quality of care received by mothers and babies in developing countries is often reported as poor. Yet efforts to address this contributory factor to maternal and newborn mortality have received less attention compared with barriers of access to care. The current heightened concern to achieve Millennium Development Goals 4 & 5 has illuminated the neglected quality agenda. Whilst there is no universally-accepted definition of “quality care”, it is widely acknowledged to embrace multiple levels – from patient to health system, and multiple dimensions, including safety as well as efficiency. Quality care should thus lie at the core of all strategies for accelerating progress towards MDG4 &5. Interventions to measure and improve quality need themselves to be evidence-based. Two promising approaches are maternal and perinatal death reviews and criterion-based audit. These and other quality improvement tools have a crucial role to play in the implementation of effective maternal and newborn care.
An urgent need…
Every year, over half a million women die of pregnancy-related causes worldwide and more than 99% of these occur in the developing world.1 Over 80% of these deaths could be prevented or avoided through timely interventions proven to be effective and affordable.2–4 In addition an estimated 4 million neonatal deaths occur each year, accounting for 36% of deaths in children <5 years.5 These newborn and maternal deaths are included in the targets of Millennium Development Goals (MDG) 4 & 5 – targets which seem unlikely to be met by 2015. Concern for these poor prospects has recently led to a new Consensus Statement on Maternal and Newborn Health (MNH).6 This calls for renewed efforts to speed-up and scale-up the implementation of effective interventions, acknowledging that it is the very lack of care that is directly responsible for many deaths during pregnancy, childbirth and the postnatal period.
Strategies to improve maternal and newborn health
The four essential pillars supporting strategies to achieve MDG4 and MDG5 are (1) family planning and access to other reproductive health services, (2) skilled care during pregnancy and delivery (including Skilled Birth Attendance (SBA), Emergency (or Essential) Obstetric Care (EOC) for maternal and newborn complications, and postnatal care for mother and baby. Quality of care is a crucial requirement for all of these four ‘pillars’.7,8
A decade ago a joint WHO/UNFPA/UNICEF/World Bank statement called on countries to ‘ensure that all women and newborns have skilled care during pregnancy, childbirth and the immediate postnatal period’.9,10 A ‘skilled attendant’ is at the core of providing the essential quality of care to ensure safe outcomes for mothers and babies. By definition, the crucial word here is ‘skilled’, often equated with ‘trained’ or ‘professional’. Increasing the proportion of deliveries with skilled attendants working within a functioning health system is widely regarded as a crucial intervention strategy and widely advocated by international agencies.11,12 The percentage of deliveries assisted by a skilled birth attendant is one of the proxy indicators for MDG5.
Two levels of EOC are defined namely the Basic EOC (BEOC) and Comprehensive CEOC (CEOC).13 A BEOC facility provides six signal functions: injectable antibiotics, oxytocics, anticonvulsants, manual vacuum aspiration, manual removal of retained placenta and assisted vaginal delivery (vacuum extraction). A CEOC facility provides caesarean section (CS) and blood transfusion (BT), in addition to all the six BEOC services. There is united agreement that the minimum acceptable coverage for a population of 500 000 is one CEOC facility and four BEOC facilities.14 The distribution of such facilities needs to be equitable.
Quality of care
Numerous studies have shown that the quality of care received by mothers and babies, and particularly marginalised groups is poor in many developing countries, so contributing to the high levels of maternal and newborn mortality.15–20 There is no universally accepted definition of quality of care, but increasingly the composite nature of quality is acknowledged. The Institute of Medicine, for example, identifies the six elements of effectiveness, safety, timeliness, efficiency, equity and responsiveness to the preferences, needs and values of mothers and their families – as individuals and populations.21
Defining quality in the context of maternal health, Hulton et al. (2000)22 incorporated the concept of both effective and timely access, and of reproductive health rights:
‘Quality of care is the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and uphold basic reproductive rights.’
This recognises the importance of two components of care: the quality of the provision of care – the service and the system, and quality of care as experienced by users. The use of services and outcomes are the result not only of the provision of care but also of women’s experience of that care. Provision of care may be deemed of high quality against recognised standards of care but unacceptable to the woman, her family and the community. Conversely, some aspects of care may be popular with women but may be ineffective or harmful to their health and that of their babies. Although this definition seems to refer to the mainly ‘formal’ health services, clearly problems of poor care are also prevalent in the informal sector and warrant attention, for example, services provided by ‘quacks’ or untrained Traditional Birth Attendants.
Turning to rights-based approaches to improving health systems and services, these have often focused on women’s access to and use of quality maternity services. A health systems analysis of the extent to which services are available, accessible, acceptable, and of the highest possible quality, can be valuable in identifying problems and designing interventions that are rights based.23 Ensuring that maternity services exist and are financially and physically accessible necessarily illuminates rights. Focusing on healthcare providers and making sure that they are accountable to women who seek care is another such approach. Quality of care is thus an essential component of any programme that upholds the basic principles of a reproductive health approach.
Over the last 20 years, the emergence of evidence-based practice has highlighted the dual importance of efficacy of intervention and effectiveness of implementation. Such practice can be seen as the conscientious, explicit and judicious use of contemporary best research evidence in making decisions about the care of individual patients.24–27 Increasingly, however, it is recognised that evidence-based practice is not only needed for individual care but also at the service, programme and policy levels. This highlights the need to look at issues of effectiveness and cost-effectiveness as well as equity of implementation. This requires robust evidence from implementation research28 and from complex evaluations of programmes and strategies, such as those conducted by Immpact.29
A vital source of evidence-based practice is research synthesis which provides a critical evaluation and summary of reliable research on the benefits and harms of health care interventions. The first systematic summaries of interventions tested in randomised controlled trials were in the area of pregnancy and childbirth. The Pregnancy and Childbirth Group of the Cochrane Collaboration conducts, promotes access to and keeps up to-date systematic reviews of randomized controlled trials of interventions in pregnancy and childbirth. For many health professionals in low- and middle-income countries, evidence-based approaches are something relatively new. A variety of strategies to change the behaviour of health professionals have been tested, such as continuing medical education or dissemination of printed materials. It is important that interventions to change practice are based on evidence as to whether they are effective or not. Passive dissemination of evidence alone, such as didactic lectures, is often not effective in changing provider practice. Interventions that promote active engagement of participants, such as through interactive workshops, audit and feedback, appear more likely to be effective.30
Tools and approaches for quality improvement
Many tools for measuring quality also act intentionally as interventions to improve quality. The evidence-base on the effectiveness and efficiency of alternative quality improvement approaches and tools is still relatively weak and urgently warrants strengthening. One recent comprehensive assessment emphasized the importance of multi-faceted approaches tailored to specific needs and contexts.31 Where the need relates, for example, to preventing maternal and newborn deaths, the audit and feedback process of gathering, reviewing and acting-upon information on these adverse events is one of the keystones to Continuous Quality Improvement strategies in MNH care.32 A Cochrane review of randomised controlled trials of audit and feedback showed a greater impact on health care practices and outcomes than other improvement strategies.30 Whilst there is an ever-expanding number of tools and approaches for improving and assuring different elements of quality, two of particular relevance to MNH are death audit and standards or criterion-based audit.
Maternal and perinatal death audit;
This audit, for instance, is an in-depth investigation of the causes of and factors (personal, family or community) that may have contributed to maternal death or perinatal death. These audits can be conducted at both community and facility level and can be used to inform strategy at facility, district, state and national level. Such systems of enquiry have been successfully introduced at national level in several resource poor countries and are similar to the confidential enquiry systems – for mother and baby – used in the United Kingdom.33,34 Findings from the enquiries have been used to identify the areas of service that need change and to develop standards for care. Maternal death reviews have been shown to bring observable changes in clinical practice through hospitals quality improvement teams.35–37
A second approach is standards- or criterion-based audit;
This is defined as ‘an objective, systematic and critical analysis of the quality of health care against set criteria (standards) of best practice’.2 Standards are set with a clear objective, and structure, process and outcome criteria. The current practice is measured and compared with the standards. Recommendations for change are made and implemented, and practice re-evaluated. Studies in a variety of resource poor setting have demonstrated the feasibility and effectiveness of using criterion-based audit to measure and improve the quality of MNH care.38–42
The way forward
Historical and contemporary experiences of maternal and newborn mortality reduction point to crucial role of timely, effective, appropriate and affordable care – in other words, to the quality of care and services provided to mothers and babies. Over the last 10–15 years, much attention has been given to narrowly-defined provision or coverage indicators as ways to track progress at national and international levels. The quality dimension has received less attention until recently, in part owing to the challenges of defining and capturing realistic indicators. However, the urgent concern to accelerate progress towards MDG 4 & 5 has illuminated the neglected quality agenda. A variety of new initiatives are emerging, including those related not only to MNH, such as the Global Alliance for Patient Safety http://www.who.int/patientsafety/worldalliance (Accessed 10 July 2009), but also those addressing broader definitions of quality, such as the newly-formed community of practice – Quality Care for Pregnancy and Childbirth (the QCPC Collaborative) http://www.qcpccollab.org (Accessed 10 July 2009). Just as the evidence-based movement over a decade ago created a culture for questioning and guiding the content of interventions, a similar shift of paradigm is needed to question and guide the quality of implementation at individual, service and health systems levels.28 This shift is long over-due. The renewed attention and resources stimulated by the 2015 deadline represent an opportunity to accelerate this shift to universal access to quality care for MNH.
Conflict of interest/Disclosure of interest
The authors have declared no conflicts of interest.
Contribution to authorship
Both authors have contributed to the design and writing of this paper.
Details of ethics approval
No ethical approval was required for this paper.
No funding was received for this paper.