Introduction

In recent years, measuring the quality of inpatient obstetrical care has attracted considerable attention, for various reasons. First, obstetrics and gynaecology involves multiple activities, including surgical procedures (e.g. caesarean section and fibroid removal), medical gynaecological care (e.g. contraception and management of the menopause), diagnostic procedures (e.g. ultrasonography), and obstetrical care (e.g. prenatal care and delivery). Second, each obstetrical admission may affect the health of not one, but two individuals. In addition, most women admitted for obstetrical reasons are healthy individuals, in whom the goal is full preservation of health, in particular through careful attention to adverse events caused by management errors. Third, obstetrics is one of the medical specialties most heavily affected by patient complaints. In 2008 in France, 66% of obstetrical malpractice lawsuits led to convictions. The same year, for each of eight serious complaints of obstetrical malpractice, the courts awarded 1–3 million Euros in damages. In the US, 89% of American College of Obstetricians and Gynecologists fellows responding to the 2006 Professional Liability Survey indicated that they had been sued during their careers. The growth of medical liability litigation is increasingly leading physicians to practice defensive medicine, which increases healthcare costs. Fourth, healthcare is now widely viewed as a commodity and patients as consumers. Thus, patients expect greater safety, higher quality of care, and access to objective data, reflecting the quality of medical services.

To improve patient outcomes, and to better meet patient expectations, healthcare authorities and professionals now use a wide range of quality-improvement tools and methods. Over the past decade, the development and implementation of quality indicators (also known as performance indicators or quality measures) has been largely driven by the introduction of computerised administrative and clinical databases, as well as by new policies requiring the publication of performance data. Many government agencies and professional bodies have developed quality indicators for various fields, with the goal of identifying aspects of clinical care that require improvement.

Healthcare quality indicators

The Institute of Medicine defines healthcare quality as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and care consistent with current professional knowledge’. Improving quality and safety of healthcare has generated considerable interest in recent years.

Quality can be improved without measurements, by implementing clinical guidelines. Moreover, quality can be assessed without using quantitative measures, such as rates of quality indicators, through peer review or patient interviews, for example. Measurement, however, plays an important part in improving quality of care and promoting beneficial changes. Therefore, over the past decade, much effort has gone into developing and using quality indicators.

One of the most widely accepted definitions of indicators is that of Marshall et al. They described indicators as ‘measurable elements of practice for which there is evidence or consensus that they reflect quality and hence help change the quality of care provided. Indicators are often based on routinely collected data, data from electronic medical records, and sometimes data from surveys’. Healthcare quality indicators are viewed as tools for decision-making and quality improvement. The effect of introducing indicator monitoring in healthcare facilities on the quality of health care has been assessed in several studies. Many government agencies and professional bodies have developed quality indicators for various fields, with the goal of improving healthcare quality by detecting suboptimal care based on the traditional Donabedian model, which assesses structures, processes, and outcomes ( Fig. 1 ). The Donabedian model is the most widely used, although other models for describing the process of quality assessment exist. In obstetrical care, it is relatively easy to apply, as its components can be readily defined.

The Donabedian model of patient safety management. Source from “The Donabedian Model of Patient Safety: Medical Teamwork and Patient Safety: The Evidence-based Relation. July 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/medteam/figure2.html ”.

Outcome indicators provide information on whether the goal of care was achieved. They include mortality, morbidity, health status, and patient satisfaction. Process indicators describe medical activities such as diagnosis, treatment, referral, and prescribing Finally, structural indicators reflect the organisation of care, particularly those relating to staffing, funding, and appointment availability. Structural indicators received limited attention, as healthcare facilities must therefore meet the structural requirements of accreditation bodies (e.g. the Haute Autorité de Santé in France, the Joint Commission on Accreditation of Healthcare Organizations in the USA, and the National Health Service in the UK).

Healthcare quality indicators

The Institute of Medicine defines healthcare quality as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and care consistent with current professional knowledge’. Improving quality and safety of healthcare has generated considerable interest in recent years.

Quality can be improved without measurements, by implementing clinical guidelines. Moreover, quality can be assessed without using quantitative measures, such as rates of quality indicators, through peer review or patient interviews, for example. Measurement, however, plays an important part in improving quality of care and promoting beneficial changes. Therefore, over the past decade, much effort has gone into developing and using quality indicators.

One of the most widely accepted definitions of indicators is that of Marshall et al. They described indicators as ‘measurable elements of practice for which there is evidence or consensus that they reflect quality and hence help change the quality of care provided. Indicators are often based on routinely collected data, data from electronic medical records, and sometimes data from surveys’. Healthcare quality indicators are viewed as tools for decision-making and quality improvement. The effect of introducing indicator monitoring in healthcare facilities on the quality of health care has been assessed in several studies. Many government agencies and professional bodies have developed quality indicators for various fields, with the goal of improving healthcare quality by detecting suboptimal care based on the traditional Donabedian model, which assesses structures, processes, and outcomes ( Fig. 1 ). The Donabedian model is the most widely used, although other models for describing the process of quality assessment exist. In obstetrical care, it is relatively easy to apply, as its components can be readily defined.

The Donabedian model of patient safety management. Source from “The Donabedian Model of Patient Safety: Medical Teamwork and Patient Safety: The Evidence-based Relation. July 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/medteam/figure2.html ”.

Outcome indicators provide information on whether the goal of care was achieved. They include mortality, morbidity, health status, and patient satisfaction. Process indicators describe medical activities such as diagnosis, treatment, referral, and prescribing Finally, structural indicators reflect the organisation of care, particularly those relating to staffing, funding, and appointment availability. Structural indicators received limited attention, as healthcare facilities must therefore meet the structural requirements of accreditation bodies (e.g. the Haute Autorité de Santé in France, the Joint Commission on Accreditation of Healthcare Organizations in the USA, and the National Health Service in the UK).

Quality indicators in obstetrics

In recent years, numerous quality measures have been proposed for obstetrical care. Some of them are listed in Table 1 . For example, in the ORYX project (National Hospital Quality Measures) of the Joint Commission on Accreditation of Healthcare Organizations, a technical advisory panel of perinatal care field selected a set of five indicators, known as the Perinatal Care measures, which includes the caesarean section rate and the use of antenatal steroids. The European Performance Assessment Tool for quality improvement in Hospitals includes the caesarean section rate among indicators used to measure performance in acute-care facilities.

The Health Care Quality Indicators project of the Organisation for Economic Co-operation and Development involves collecting data on obstetrical trauma (during caesarean section, operative vaginal delivery, and non-operative vaginal delivery) and on neonatal morbidity. The EURO-PERISTAT project, a European collaborative effort conducted as part of the European Commission’s Health Monitoring Programme, has developed perinatal health indicators for healthcare professionals, policy makers, researchers, and health service users who wish to monitor and evaluate perinatal health. The aim of this project, which included 13 countries, was to facilitate monitoring and comparison by harmonising indicator definitions and encouraging the collection of comparable data. A list of 10 core indicators and 20 recommended indicators was established. These indicators chiefly reflect maternal and neonatal morbidity. Of the 20 indicators, seven require further work to develop universally accepted definitions. In France, the COMPAQ-HPST project aims to develop healthcare quality indicators for widespread use in healthcare facilities, and to establish effective ways of using these indicators. The prevention and management of postpartum haemorrhage is among the topics of the COMPAQ-HPST project. Finally, professional bodies, such as the Norwegian Gynecological Society from the Nordic Federation of Societies of Obstetrics and Gynecology , the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and the Australian Council on Healthcare Standards have also listed candidate indicators for monitoring the quality of care in maternity units. Draycott et al. identified 290 maternity outcomes in 96 clinical categories published by four national organisations (Royal College of Obstetricians and Gynaecologists, American College of Obstetricians and Gynecologists, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and Society of Obstetricians and Gynaecologists of Canada).

Several studies have led to the development of new tools for quality measurement in obstetrics. For example, Mann et al. developed three obstetrical quality-improvement outcome tools: the Adverse Outcome Index, Weighted Adverse Outcome Score, and Severity Index. The Adverse Outcome Index is the per cent of deliveries with one or more of the adverse events listed in Table 1 , which include maternal death and third and fourth-degree tears. The Weighted Adverse Outcome Score is the adverse event score per delivery, computed as the sum of points assigned to deliveries with adverse outcomes divided by the total number of deliveries. The Severity Index is the sum of adverse outcome scores divided by the number of deliveries with identified adverse outcomes. Other measures have been suggested, such as the risk-adjusted primary caesarean rate. This rate is not affected by variations in patient populations across hospitals, but instead chiefly reflects variations in quality of care. All these measures, however, require validation and are, therefore, not suitable for use until further data become available.