Skip to 0 minutes and 13 secondsPROF SUELLEN MILLER: Following a previous mini-lecture on pathways to inequalities, in this step we will focus on quality of care. What is quality of care in health? The most comprehensive model used for health care evaluation and planning is Donabedian's Model, first published in 1966. In this model, there are three distinct aspects of quality, which include structure, process, and outcomes. Structure is the physical and policy setting where care takes place, including adequate resources. Processes of care are the actual activities that constitute care, including prevention, diagnosis, and treatment. Quality of care is a major multi-factorial concept in health. The concept not only includes actions, but also interactions and relationships between many components.

Skip to 1 minute and 8 secondsThe three major components of quality for maternal health are respectful care, the appropriate amount of care-- neither "too little, too late" nor "too much, too soon"-- and of course, evidence-based clinical practice guidelines defined as systematically developed statements to aid clinicians' decision making about what is the best clinical care for a specific set of clinical conditions. High quality, evidence-based guidelines are developed in a structured review process that is based on the best evidence existing for or against an intervention. If followed, this should result in increased use of services, reduction in the use of inappropriate or unnecessary services, and cost effectively reduce negative outcomes.

Skip to 2 minutes and 3 secondsThe World Health Organisation's Quality of Care framework for Maternal and Newborn Health is adapted from the Donabedian Model. Process steps include not only the provision of care, but the woman's experience of care. Under process, the very first element is practice based on evidence-based guidelines. Under the experience of care, there are actions and interactions between women and their health

Skip to 2 minutes and 32 secondscare providers: effective communication, respect and dignity, and emotional support. What is quality maternal health care? In quality care, we're striving to achieve a balance between care that is "too little, too late" or "too much, too soon", but what can be called

Skip to 2 minutes and 53 secondsright care: appropriate, timely, evidence-based, and respectful. Many of the factors in "too little, too late" are structural, but are also marked by inadequate adherence to evidence-based guidelines, whether due to not knowing what they are, or using outdated or low quality guidelines, or an inability to apply quality guidelines because of inadequate resources or even confusion over what are the right evidence-based practices. In high-income countries and among certain population groups in low- and middle-income countries, practices that are 'too much, too soon' are marked by over-medicalisation.

Skip to 3 minutes and 34 secondsThese might be lifesaving interventions when used appropriately, such as Caesarean delivery, but when administered without respect or used routinely, these actions and interventions may raise costs and result in decreased community acceptance of facility-based care, or fear of service at a facility. It's important to remember that "too little, too late", and "too much, too soon" can occur simultaneously in the same country. The paper by Miller and colleagues was unique in examining conflicting recommendations. Quality depends on consistent application of guidelines, yet a lack of consensus among guideline developers can lead to confusion and a lack of adherence. Further confusing is the use of different systems for grading of evidence, as different terminology has created confusion for users and policymakers.

Skip to 4 minutes and 36 secondsIn conclusion, the quality of care is essential to achieve better outcomes, greater satisfaction with experience of care, and improve the likelihood of women delivering at facilities with skilled providers. All women and newborns have the right to be treated respectfully to the highest quality of care based on the best evidence, at the appropriate time.

What is quality maternal health care?

What are the multiple-factorial components of quality of care in maternal health?

In this step Prof Suellen Miller (UCSF) defines what quality of care is encompassing respectful care; the appropriate amount of care – neither “too little, too late” nor “too much, too soon”; and evidence-based clinical practice guidelines. Reference to the WHO Quality of Care Framework for Maternal and Newborn Health explains how to achieve better outcomes, satisfaction and experiences among women.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine