An image of a dirty sink and tap is shown.
This is the hand-washing sink in the labour room of a rural primary health care centre in Nepal. Running water is only available for limited times each day.

Overview of WHO's quality care framework for maternal and newborn care

The renewed focus on understanding quality of care was triggered in part with the realisation that many of the Millennium Development Goal (MDG) targets and indicators focused more on coverage (or quantity). In the MDG evaluations undertaken in a number of countries, the expected health gains from increased coverage didn’t occur, partly due to a lack of quality care.

Consider the following countries. The first indicator, SBA coverage %, gives the proportion of deliveries with a skilled birth attendant (SBA), which was the main indicator for the fifth MDG goal of maternal mortality reduction. Compare this with the two indicators of actual health outcomes: maternal mortality ratio (MMR) - the proportion of pregnant women who die as a result of pregnancy or childbirth - and the lifetime risk of maternal death.

Country SBA coverage (%) MMR Lifetime risk of maternal death
Bolivia 86 . 206 1 in 140
Bangladesh 42 176 1 in 250
Lesotho 78 490 1 in 64
Philippines 73 250 1 in 120
Rwanda 91 320 1 in 66
Burundi 60 712 1 in 22
Source: Countdown Report 2015

Across all the Countdown countries (for Countdown 2015 this included the 75 countries with the highest burden of maternal, newborn and child deaths) there is an association between higher levels of skilled birth attendance and lower MMR, and no country with a SBA level below 50 has an MMR below 200. However, it is not a linear relationship and there are many settings with similar levels of skilled birth attendance who have widely differing maternal mortality ratios (compare Lesotho and the Philippines in the table above).

Similarly, you may see countries with a similar MMR who have very different SBA coverage (compare Bolivia and Bangladesh). Context matters, and often the quality of the care was what made the difference. Yet because the MDG focus was on scaling up skilled attendance at birth, the opportunity to address quality of care gaps was often overlooked during the MDG period.

One of the problems is that, to date, we haven’t had a consistent way to define and think about quality of care, and consequently we have had difficulties in measuring it. And, as we have said many times to date, we manage what we measure, so if we don’t measure something well, our health system may not give it much attention.

As you have heard in the previous step, a number of quality care frameworks have been described. The systems model is the most commonly used, and in 2015 WHO published their framework. As you can see, it incorporates a little of the characteristics and the systems models. It recognises that there are differences in the provision and experience of care and it takes account of the structure, process and outcomes of care.

The WHO framework

Source image: Fig 1 in Tunçalp, Ӧ., Were, W.M., MacLennan, C., Oladapo, O.T., Gülmezoglu, A.M., Bahl, R., Daelmans, B., Mathai, M., Say, L., Kristensen, F. and Temmerman, M., 2015. Quality of care for pregnant women and newborns—the WHO vision. BJOG: an international journal of obstetrics & gynaecology, 122(8), pp.1045-1049.

But as you would recognise having done so much of this course, as with any framework it risks being a static system with all the disadvantages of not recognising complexity. It is great to see the equivalent status give to the provision of care and the experience of care, given that experience of care is a relatively new focus.

Quality care indicators

Of course, frameworks work best when they are matched with measurable indicators. If we take the example of the WHO framework for quality maternal and newborn care, in 2013 a consultation was held to come up with a core set of quality indicators for maternal, newborn and child health. These form the precursor to the 2016 WHO publication of their Standards for Improving Quality of Maternal And Newborn Care in Health Facilities, which we will review in a subsequent step. In the 2013 consultation the following are the agreed indicators:

Mothers

  • Proportion of antenatal care visits at which blood pressure was measured
  • Proportion of women receiving oxytocin within 1 min of birth of infant
  • Proportion of women with severe preeclampsia or eclampsia treated with magnesium sulfate injection
  • Proportion of women with prolonged labour
  • Intrapartum stillbirth rate
  • Proportion of women with severe systemic infection or sepsis in postnatal period, including readmissions.

Newborns

  • No. of health facilities with functional bags and masks (two neonatal mask sizes) in the delivery areas of maternity services
  • Proportion of newborns who received all four elements of essential care: immediate and thorough drying; immediate skin-to-skin contact; delayed cord clamping; initiation of breastfeeding in the first hour
  • Facility neonatal mortality rate disaggregated by birthweight: > 4000 g, 2500–3999 g, 2000–2499 g, 1500–1999 g, < 1500 g
  • Proportion of health facilities in which Kangaroo Mother Care is operational by level of facility
  • Proportion of health facilities offering maternity services certified by the Baby-friendly Hospital Initiative and recertification not older than 2 years.

Children

  • Proportion of children who are correctly prescribed an antibiotic for pneumonia
  • Proportion of children requiring referral who receive correct pre-referral treatment and referral
  • Proportion of children with severe acute malnutrition who are correctly prescribed therapeutic feeding
  • Death rate of hospitalised children under 5 years.

General

  • Proportion of health facilities that had stock-outs of essential lifesaving medicines for mothers, newborns and children in a specified period
  • Proportion of maternal, perinatal and child deaths, occurring in a facility, that were reviewed
  • Proportion of health facilities with soap and running water or alcohol-based rub available in labour, childbirth, neonatal and paediatric wards
  • Proportion of health facilities with safe, uninterrupted oxygen supply in childbirth, neonatal and paediatric wards.

Indicators might be easy to define but they are not always easy to report against. Let’s look a little more closely at just the six maternal indicators for quality.

The table below outlines how each indicator needs to be calculated, and from where data might be available.

Core indicator Numerator Denominator Data source Methods
1. Proportion of antenatal care visits at which blood pressure was measured No. of antenatal care visits at which blood pressure was measured Total no. of antenatal care visits Antenatal care registry or hand-held prenatal record (facility-specific) Collected by delegated staff from available records
2. Proportion of women receiving oxytocin within 1 min of birth of infant No. of women receiving oxytocin immediately after birth of the infant and before birth of placenta, irrespective of mode of delivery Total no. of women giving birth in the health facility Birth unit registry, patient records Collected by delegated staff from available records or chart review
3. Proportion of women with severe preeclampsia or eclampsia treated with magnesium sulfate injection No. of women with severe preeclampsia or eclampsia treated with magnesium sulfate injection Total no. of women with severe preeclampsia or eclampsia Birth unit or maternity registry Collected by delegated staff from available records
4. Proportion of women with prolonged labour No. of women who have not given birth or were not transferred out within 12 h of active labour Total no. of women in active labour in the health facility Generally available through birth records, partographs Collected by delegated staff from available records
5. Intrapartum stillbirth rate No. of stillborn infants weighing > 1000 g and fetal heart rate documented on admission Total no. of births of infants weighing > 1000 g in facility Admission and labour ward registry, partographs Collected by delegated staff from available records
6. Proportion of women with severe systemic infection or sepsis in postnatal period, including readmissions No. of women seen in the facility with severe systemic infection or sepsis in postnatal period, including readmissions after birth in facility Total no. of women giving birth in the health facility Admission and discharge records Collected by delegated staff from available records

Efforts to measure quality are important, and the suggested indicators are relevant, but until we have better recording systems many of these indicators are not reportable using current data. Take the example of the treatment of high blood pressure (eclampsia, in indicator 3 above). In poor quality systems eclampsia may not always be diagnosed, and so the recorded proportion treated will be very inaccurate.

Sadly, our current levels of monitoring quality are very imprecise.


Consider the six indicators in the table above. In your setting are each of these routinely measured? And if so how reliable is the data? Are you confident of the accurate recording of the denominators within each indicator?


References
Requejo, J, Victora, CG & Bryce, J, 2015, A decade of tracking progress for maternal, newborn and child survival: The 2015 Report.
Tunçalp, Ӧ, Were, WM, MacLennan, C, Oladapo, OT, Gülmezoglu, AM, Bahl, R, Daelmans, B, Mathai, M, Say, L, Kristensen, F & Temmerman, M, 2015, ‘Quality of care for pregnant women and newborns—the WHO vision’, BJOG: an international journal of obstetrics & gynaecology, vol. 122, no. 8, pp. 1045-1049.

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