Quality of care during labour and childbirth and in the immediate postnatal period is important in ensuring healthy maternal and newborn survival. A narrative review of existing quality frameworks in the context of evidence-based interventions for essential care demonstrates the complexities of quality of care and the domains required to provide high quality of care. The role of the care provider is pivotal to optimum care; however, providers need appropriate training and supervision, which should include assessment of core competencies. Organisational factors such as staffing levels and resources may support or hinder the delivery of optimum care and should be observed during any monitoring. The woman’s perspective is central to all quality of care strategies; her opinion should be sought where possible. The importance of assessing and monitoring quality of care during such a critical period should be appreciated. A number of quality frameworks offer organisations with a foundation on which they can deliver high quality care.
Highlights
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The period around birth is critical for maternal and newborn survival.
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Quality of care is fundamental to improve maternal and neonatal outcomes.
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A multi-disciplinary effort is required to ensure that high quality of care is delivered.
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Monitoring of quality of care is pivotal to improve and maintain standards.
Defining quality of care
Defining what is meant by ‘quality’ has been a global challenge. Consequently, there are several definitions of the term used in relation to healthcare and/or health systems. Defining ‘quality’ is important if one is to explore its relationship to outcomes, the processes of assessment and the mechanisms for continual monitoring. Noticeable definitions stem back to the 1960s, with Donabedian stating: ‘ Quality of care is the extent to which actual care is in conformity with present criteria for good care’ [ , pg. 166] Although a limited definition, it does acknowledge the concept of ‘best practice’ or ‘gold standards’ which are pivotal to providing quality care. Donabedian’s model of quality of care separates the attributes into three useful domains: (1) structure; this includes the physical environment, facilities, equipment, organisational systems, administrative processes and staffing (levels, leadership, structure, qualifications and finances); (2) process: diagnosis, treatment, interventions, referrals, communication and continuity; and (3) outcomes: clinical outcomes, mortality, morbidity and satisfaction. A deficit in any one of these domains can impact the others.
The Institute of Medicine offered a further definition of quality of healthcare, which provided a greater description of its components: ‘ The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’ [pg. 1] This definition acknowledges the timeliness of quality of care.
The World Health Organization (WHO) [ , pg. 9–10] offers a more comprehensive definition which includes six dimensions of quality. These dimensions require that healthcare be:
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effective , delivering healthcare that is evidence based and results in improved health outcomes for individuals and communities, based on need;
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efficient , delivering healthcare in a way that optimises resources;
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accessible , delivering healthcare that is timely, reachable and provided in locations where appropriate skills are available;
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acceptable/client-centred , delivering healthcare which considers the preferences and aspirations of individual service users and the cultures of their communities;
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equitable , delivering the same quality of healthcare to all, regardless of individual characteristics such as gender, race, ethnicity, geographical location or socioeconomic status;
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safe , delivering healthcare which maximises the safety of users and minimises risks.
The WHO definition provides a good foundation on which facilities can monitor their own provision of care, identifying areas of weakness and identifying solutions to improve the quality. It is likely that all dimensions are required to deliver high quality care.
Many more definitions exist in the literature, specifically related to maternal and newborn health [e.g. ]; the common components of which are providing a high level of essential evidence-based care to all women and newborns and a higher level of care to those with complications. The WHO’s package of interventions for the integrated management of pregnancy and childbirth (IMPAC) provides evidence-based recommendations to ensure the best outcomes for mother and newborns . However, this care should be provided in a way that satisfies women and their families, supports the care provider and has a good organisational and financial framework. It is no longer acceptable for facilities to focus solely on health goals. Indeed, there has been a realisation that health goals and quality goals are inter-related , and therefore should be addressed simultaneously. Examples from within the maternity continuum can be seen in Table 1 .
| Health goal: Improve the uptake of focussed antenatal care |
| Quality goal: Ensure that the antenatal service offered is acceptable and desirable to women. |
| Health goal: To reduce obstructed labour in women living in rural communities |
| Quality goal: To improve local access to health services |
| Health goal: To increase the number of women using family planning methods |
| Quality goal: To increase women’s knowledge and understanding of available family planning methods |
Ultimately, improving quality of care should result in improved clinical outcomes.
Building on the WHO definition of quality of care , a framework has been developed to conceptualise quality of care for maternal and newborn health [ Fig. 1 ], as part of a vision for continual quality improvements.
To support the WHO’s vision to end preventable mortality and morbidity among mothers and newborns, six strategic areas have been identified . Fig. 2 highlights the evidence-based approach to the strategy which includes a systematic approach to (1) research, (2) guideline development, (3) standards of care, (4) effective intervention identification, (5) development of monitoring indicators and (6) capacity strengthening. It is proposed that activities in these strategic areas will not only support the maternal and newborn quality of care improvement strategy, but will also support targeted country-level capacity building. At a local level, having an action plan that incorporates all elements of the framework is likely to improve outcomes.
Why quality of care is important?
Provision of quality of care is important for all facilities and should be expected by all individuals. However, some aspects of quality are unique to a maternity population. As outlined by Pitroff et al. , a balance is needed so that pregnant women who are healthy and free from complications are not over-managed and those who have unpredictable complications are not under-managed. Furthermore, consideration needs to be given to the mother-baby dyad, as interventions for one will impact the other. Additionally, and unlike some other disciplines, the nature of maternity care makes it an emotionally and culturally sensitive period, a factor that can also impact quality of care. Scaling up the use of skilled maternity care is pivotal to the reduction of mortality and morbidities; nevertheless, availability does not guarantee uptake. Coast et al. , for example, propose that women from minority cultural groups may not access a service because they are poor or that they anticipate discrimination. Several papers support the notion that cultural factors influence women’s use of services , and thus highlight the need for culture to be incorporated into the planning of quality of care strategies.
Globally, maternal and neonatal mortality rates remain high, with 800 women and 7700 newborns continuing to die each day from complications occurring during pregnancy and childbirth and in the postnatal period; in addition, approximately 7300 women experience a stillbirth . Quality of care has a pivotal role in reducing these rates. Quality of care focusses on the way services are delivered, as opposed to what services are delivered; therefore, provision of care and quality of care are integral to each other. A useful example is the availability of a skilled workforce to support births in hospitals. The fact that the service is available does not automatically equate to the pregnant woman accessing this service. To ensure quality of care, the woman would need to be able to (a) know that the service is available, (b) have access to the service (transport, resources etc.) and (c) have the desire to access the service, in the knowledge that she will be greeted cordially when she arrives.
Quality is a dominant feature in the strategy towards ending preventable maternal mortality (EPMM) . As shown in Table 2 , appropriate care and support go beyond the delivery of clinical care. The EPMM is framed within a human rights approach, recognising that inequalities are a major contributor to mortalities. The strength of this approach is the recognition of the political, social and economic impact on outcomes.
| Ultimate Goal: Ending Preventable Maternal Mortality |
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Guiding principles for EPMM
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Cross-cutting actions for EPMM
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Five strategic objectives towards EPMM
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Closely aligned to the EPMM is the Every Newborn Action Plan (ENAP) , a strategy that advocates for high quality care, aimed at eliminating preventable newborn deaths and stillbirths. This action plan has five strategic objectives:
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Strengthen and invest in care during labour, childbirth and the first day and week of life.
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Improve the quality of maternal and newborn care.
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Reach every woman and every newborn to reduce inequities.
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Harness the power of parents, families and communities.
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Count every newborn – measurement, programme tracking and accountability.
The strategy and subsequent packages of care [ Fig. 3 ] are designed based on the knowledge that over a third of stillbirths, three-quarters of newborn deaths and 72% of maternal deaths happen during this period , many of which can be prevented by high quality of care. To eradicate avoidable maternal and newborn deaths and stillbirths, high-impact, cost-effective interventions are necessary, as outlined in Fig. 3 .
Why quality of care is important?
Provision of quality of care is important for all facilities and should be expected by all individuals. However, some aspects of quality are unique to a maternity population. As outlined by Pitroff et al. , a balance is needed so that pregnant women who are healthy and free from complications are not over-managed and those who have unpredictable complications are not under-managed. Furthermore, consideration needs to be given to the mother-baby dyad, as interventions for one will impact the other. Additionally, and unlike some other disciplines, the nature of maternity care makes it an emotionally and culturally sensitive period, a factor that can also impact quality of care. Scaling up the use of skilled maternity care is pivotal to the reduction of mortality and morbidities; nevertheless, availability does not guarantee uptake. Coast et al. , for example, propose that women from minority cultural groups may not access a service because they are poor or that they anticipate discrimination. Several papers support the notion that cultural factors influence women’s use of services , and thus highlight the need for culture to be incorporated into the planning of quality of care strategies.
Globally, maternal and neonatal mortality rates remain high, with 800 women and 7700 newborns continuing to die each day from complications occurring during pregnancy and childbirth and in the postnatal period; in addition, approximately 7300 women experience a stillbirth . Quality of care has a pivotal role in reducing these rates. Quality of care focusses on the way services are delivered, as opposed to what services are delivered; therefore, provision of care and quality of care are integral to each other. A useful example is the availability of a skilled workforce to support births in hospitals. The fact that the service is available does not automatically equate to the pregnant woman accessing this service. To ensure quality of care, the woman would need to be able to (a) know that the service is available, (b) have access to the service (transport, resources etc.) and (c) have the desire to access the service, in the knowledge that she will be greeted cordially when she arrives.
Quality is a dominant feature in the strategy towards ending preventable maternal mortality (EPMM) . As shown in Table 2 , appropriate care and support go beyond the delivery of clinical care. The EPMM is framed within a human rights approach, recognising that inequalities are a major contributor to mortalities. The strength of this approach is the recognition of the political, social and economic impact on outcomes.
| Ultimate Goal: Ending Preventable Maternal Mortality |
|---|
Guiding principles for EPMM
|
Cross-cutting actions for EPMM
|
Five strategic objectives towards EPMM
|
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