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Vallely LH, Shalit A, Nguyen R, Althabe F, Pingray V, Bonet M, Armari E, Bohren M, Homer C, Vogel JP. Intrapartum care measures and indicators for monitoring the implementation of WHO recommendations for a positive childbirth experience: a scoping review. BMJ Open 2023; 13:e069081. [PMID: 37993161 PMCID: PMC10668293 DOI: 10.1136/bmjopen-2022-069081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 09/29/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVE We aimed to identify all available studies describing measures or indicators used to monitor 41 intrapartum care practices described in the 2018 WHO intrapartum care recommendations, with a view to informing development of standardised measurement of implementing these recommendations. DESIGN Systematic scoping review. METHODS We conducted a scoping review to identify studies reporting measures of intrapartum care published between 1 January 2000 and 28 June 2021. Primary and secondary outcome measures included study characteristics (publication year, journal, country and World Bank classification) and intrapartum care measure characteristics (definition, numerator, denominator, measurement level and measurement approach). We searched MEDLINE, EMBASE, CINAHL, Cochrane Library, the Maternity and Infant Care Database, Global Index Medicus and grey literature using structured search terms related to included recommendations, focusing on respectful and supportive care, and clinical practices performed throughout labour and birth. The measures identified were classified by the WHO recommendation and their characteristics reported. RESULTS We identified 150 studies which described 1331 intrapartum care measures. These measures corresponded to 35 of the 41 included WHO recommendations, and represented all domains of the WHO recommendations (care throughout labour and birth, first stage of labour, second stage of labour, third stage of labour). A total of 40.1% (534 of 1331 measures) of measures were related to respectful maternity care. Most studies used a questionnaire or survey measurement approach (522 of 1331 measures, 39.2%). CONCLUSION This scoping review presents a database of existing intrapartum care measures used to monitor the quality of intrapartum care globally. There is no clear consensus on a core set of measures for evaluating the practice of the WHO's intrapartum care recommendations. This review provides a foundation to support the development of a core set of internationally standardised intrapartum care measures for the WHO intrapartum care recommendations, highlighting key areas requiring consensus and validation, and measure development.
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Affiliation(s)
- Lauren Hannah Vallely
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anna Shalit
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Renae Nguyen
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Fernando Althabe
- Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Verónica Pingray
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Mercedes Bonet
- Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Elizabeth Armari
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Meghan Bohren
- Centre for Health Equity, University of Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Caroline Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Joshua Peter Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Leslie HH, Hategeka C, Ndour PI, Nimako K, Dieng M, Diallo A, Ndiaye Y. Stability of healthcare quality measures for maternal and child services: Analysis of the continuous service provision assessment of health facilities in Senegal, 2012-2018. Trop Med Int Health 2021; 27:68-80. [PMID: 34865274 PMCID: PMC9300084 DOI: 10.1111/tmi.13701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective High‐quality healthcare is essential to ensuring maternal and newborn survival. Efficient measurement requires knowing how long measures of quality provide consistent insight for intended uses. Methods We used a repeated health facility assessment in Senegal to calculate structural and process quality of antenatal care (ANC), delivery and child health services in facilities assessed 2 years apart. We tested agreement of quality measures within facilities and regions. We estimated how much input‐adjusted and process quality‐adjusted coverage measures changed for each service when calculated using quality measurements from the same facilities measured 2 years apart. Results Over 6 waves of continuous surveys, 628 paired assessments were completed. Changes at the facility level were substantial and often positive, but inconsistent. Structural quality measures were moderately correlated (0.40–0.69) within facilities over time, more so in hospitals; correlation was <0.20 for process measures based on direct observation of ANC and child visits. Most measures were more strongly correlated once averaged to regions; process quality of child services was not (−0.32). Median relative difference in national‐adjusted coverage estimates was 6.0%; differences in subnational estimates were largest for process quality of child services (19.6%). Conclusion Continuous measures of structural quality demonstrated consistency at regional levels and in higher level facilities over 2 years; results for process measures were mixed. Direct observation of child visits provided inconsistent measures over time. For other measures, linking population data with health facility assessments from up to 2 years prior is likely to introduce modest measurement error in adjusted coverage estimates.
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Affiliation(s)
- Hannah H Leslie
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, USA.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Celestin Hategeka
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Papa Ibrahima Ndour
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal.,Agence Nationale de la Démographie et de la Statistique, Dakar, Senegal
| | | | - Mamadou Dieng
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal
| | - Abdoulaye Diallo
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal
| | - Youssoupha Ndiaye
- Directorate of Planning, Research, and Statistics, Ministry of Health and Social Action, Dakar, Senegal
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Kim MK, Baumgartner JN, Headley J, Kirya J, Kaggwa J, Egger JR. Medical record bias in documentation of obstetric and neonatal clinical quality of care indicators in Uganda. J Clin Epidemiol 2021; 136:10-19. [PMID: 33667620 DOI: 10.1016/j.jclinepi.2021.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 11/30/2020] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To achieve a high quality of care (QoC), accurate measurements are needed. This study evaluated the validity of QoC data from the medical records for childbirth deliveries and assessed whether medical records can be used to evaluate the efficacy of interventions to improve QoC. STUDY DESIGN AND SETTING This study was part of a larger study of QoC training program in Uganda. Study data were collected in two phases: (1) validation data from 321 direct observations of deliveries paired with the corresponding medical records; (2) surveillance data from 1,146 medical records of deliveries. Sensitivity, specificity, and predictive values were used to measure the validity of the medical record from the validation data. Quantitative bias analysis was conducted to evaluate QoC program efficacy in the surveillance data using prevalence ratio and odds ratio. RESULTS On average, sensitivity (84%) of the medical record was higher than the specificity (34%) across 11 QoC indicators, showing a higher validity in identifying the performed procedure. For 5 out of 11 indicators, bias-corrected odds ratios and prevalence ratios deviated significantly from uncorrected estimates. CONCLUSION The medical records demonstrated poor validity in measuring QoC compared with direct observation. Using the medical record to assess QoC program efficacy should be interpreted carefully.
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Affiliation(s)
- Min Kyung Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Joy Noel Baumgartner
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27708, USA
| | - Jennifer Headley
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27708, USA
| | | | - James Kaggwa
- Makerere University - Johns Hopkins University (MI-JHU) Research Collaboration, Kampala, Uganda
| | - Joseph R Egger
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27708, USA.
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Wilhelm D, Lohmann J, De Allegri M, Chinkhumba J, Muula AS, Brenner S. Quality of maternal obstetric and neonatal care in low-income countries: development of a composite index. BMC Med Res Methodol 2019; 19:154. [PMID: 31315575 PMCID: PMC6637560 DOI: 10.1186/s12874-019-0790-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 06/27/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In low-income countries, studies demonstrate greater access and utilization of maternal and neonatal health services, yet mortality rates remain high with poor quality increasingly scrutinized as a potential point of failure in achieving expected goals. Comprehensive measures reflecting the multi-dimensional nature of quality of care could prove useful to quality improvement. However, existing tools often lack a systematic approach reflecting all aspects of quality considered relevant to maternal and newborn care. We aim to address this gap by illustrating the development of a composite index using a step-wise approach to evaluate the quality of maternal obstetric and neonatal healthcare in low-income countries. METHODS The following steps were employed in creating a composite index: 1) developing a theoretical framework; 2) metric selection; 3) imputation of missing data; 4) initial data analysis 5) normalization 6) weighting and aggregating; 7) uncertainty and sensitivity analysis of resulting composite score; 8) and deconstruction of the index into its components. Based on this approach, we developed a base composite index and tested alternatives by altering the decisions taken at different stages of the construction process to account for missing values, normalization, and aggregation. The resulting single composite scores representing overall maternal obstetric and neonatal healthcare quality were used to create facility rankings and further disaggregated into sub-composites of quality of care. RESULTS The resulting composite scores varied considerably in absolute values and ranges based on method choice. However, the respective coefficients produced by the Spearman rank correlations comparing facility rankings by method choice showed a high degree of correlation. Differences in method of aggregation had the greatest amount of variation in facility rankings compared to the base case. Z-score standardization most closely aligned with the base case, but limited comparability at disaggregated levels. CONCLUSIONS This paper illustrates development of a composite index reflecting the multi-dimensional nature of maternal obstetric and neonatal healthcare. We employ a step-wise process applicable to a wide range of obstetric quality of care assessment programs in low-income countries which is adaptable to setting and context. In exploring alternative approaches, certain decisions influencing the interpretation of a given index are highlighted.
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Affiliation(s)
- Danielle Wilhelm
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Julia Lohmann
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Jobiba Chinkhumba
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3 Malawi
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre 3 Malawi
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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Abstract
Purpose The purpose of this paper is to describe a quality improvement (QI) intervention in primary health facilities providing childbirth care in rural Southern Tanzania. Design/methodology/approach A QI collaborative model involving district managers and health facility staff was piloted for 6 months in 4 health facilities in Mtwara Rural district and implemented for 18 months in 23 primary health facilities in Ruangwa district. The model brings together healthcare providers from different health facilities in interactive workshops by: applying QI methods to generate and test change ideas in their own facilities; using local data to monitor improvement and decision making; and health facility supervision visits by project and district mentors. The topics for improving childbirth were deliveries and partographs. Findings Median monthly deliveries increased in 4 months from 38 (IQR 37-40) to 65 (IQR 53-71) in Mtwara Rural district, and in 17 months in Ruangwa district from 110 (IQR 103-125) to 161 (IQR 148-174). In Ruangwa health facilities, the women for whom partographs were used to monitor labour progress increased from 10 to 57 per cent in 17 months. Research limitations/implications The time for QI innovation, testing and implementation phases was limited, and the study only looked at trends. The outcomes were limited to process rather than health outcome measures. Originality/value Healthcare providers became confident in the QI method through engagement, generating and testing their own change ideas, and observing improvements. The findings suggest that implementing a QI initiative is feasible in rural, low-income settings.
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Affiliation(s)
- Jennie Jaribu
- Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Suzanne Penfold
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Fatuma Manzi
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Joanna Schellenberg
- Department of Disease Control and Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Larson E, Vail D, Mbaruku GM, Mbatia R, Kruk ME. Beyond utilization: measuring effective coverage of obstetric care along the quality cascade. Int J Qual Health Care 2017; 29:104-110. [PMID: 27920246 DOI: 10.1093/intqhc/mzw141] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 11/16/2016] [Indexed: 11/12/2022] Open
Abstract
Objective To determine the effective coverage of obstetric care in a rural Tanzanian region and to assess differences in effective coverage by wealth. Design Cross-sectional structured interviews. Setting Pwani Region, Tanzania. Participants The study includes 24 rural, government-managed, primary healthcare clinics and their catchment populations. From January-April 2016, we conducted a household survey of a census of women with recent deliveries, health worker knowledge surveys and facility audits. Main Outcome Measures We explored the proportion of women receiving quality care through the cascade and conducted an equity analysis by wealth. Results In total, 2,910 of 3,564 women (81.6%) reported delivering their most recent child in a health facility, 1,096 of whom delivered in a study facility. Using a minimum threshold of quality, the effective coverage of obstetric care was 25%. Quality was lowest in the emergency care dimensions, with the average score on the provider knowledge tests at 47% and the average provision of basic emergency obstetric services below 50%. The wealthiest 20% of women were 4.1 times as likely to deliver in facilities offering at least the minimum threshold of quality care through the cascade compared to the poorest 80% of women (95% confidence interval: 1.5-11.3). Conclusions Effective coverage of delivery care is very low, particularly among poorer women. Health worker knowledge caused the sharpest decline in effective coverage. Measures of effective coverage are a better performance measure of under-resourced health systems than utilization. Equity analyses can further identify important discrepancies in quality across socio-economic levels. Trial Registration ISRCTN 17107760.
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Affiliation(s)
- Elysia Larson
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Bldg 1, 11th floor, Boston, MA 02115, USA
| | - Daniel Vail
- Stanford University School of Medicine, 291 Campus Drive, Palo Alto, CA 94305, USA
| | - Godfrey M Mbaruku
- Ifakara Health Institute, P.O. Box 78373, Plot 463, Kiko Avenue, Mikocheni A, Mwai Kibaki Road, Dar es salaam, United Republic of Tanzania
| | - Redempta Mbatia
- Tanzania Health Promotion Support, 3rd Floor, Coco Plaza Bldg, Plot 254, Masaki Dar es Salaam, United Republic of Tanzania
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Bldg 1, 11th floor, Boston, MA 02115, USA
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Canavan ME, Brault MA, Tatek D, Burssa D, Teshome A, Linnander E, Bradley EH. Maternal and neonatal services in Ethiopia: measuring and improving quality. Bull World Health Organ 2017; 95:473-477. [PMID: 28603314 PMCID: PMC5463811 DOI: 10.2471/blt.16.178806] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 12/06/2016] [Accepted: 01/30/2017] [Indexed: 11/29/2022] Open
Abstract
Problem Maternal and neonatal mortality remains high in low- and middle-income countries, with poor quality of intrapartum care as a barrier to further progress. Approach We developed and tested a method of measuring the quality of maternal and neonatal care that could be embedded in a larger national performance management initiative. The tool used direct observations and medical record reviews to score quality in nine domains of intrapartum care. We piloted and evaluated the tool in visits to the 18 lead hospitals that have responsibility to promote and coordinate quality improvement efforts within a hospital cluster in Ethiopia. Between baseline and follow-up assessments, staff from a national quality collaborative alliance provided hospital-based training on labour and delivery services. Local setting Ethiopia has invested in hospital quality improvement for more than a decade and this tool was integrated into existing quality improvement mechanisms within lead hospitals, with the potential for scale-up to all government hospitals. Relevant changes Significant improvements in quality of intrapartum care were detected from baseline (June–July 2015) to follow-up (February–March 2016) in targeted hospitals. The overall mean quality score rose from 65.6 (standard deviation, SD: 10.5) to 91.2 (SD: 12.4) out of 110 items (P < 0.001). Lessons learnt The method was feasible, requiring a total of 3 days and two to three trained data collectors per hospital visit. It produced data that detected substantial changes made during 8 months of national hospital quality improvement efforts. With additional replication studies, this tool may be useful in other low- and middle-income countries.
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Affiliation(s)
- Maureen E Canavan
- Global Health Leadership Institute, Yale University School of Public Health, 2 Church Street South, New Haven, Connecticut, 06519, United States of America
| | - Marie A Brault
- Global Health Leadership Institute, Yale University School of Public Health, 2 Church Street South, New Haven, Connecticut, 06519, United States of America
| | - Dawit Tatek
- Global Health Leadership Institute, Yale University School of Public Health, 2 Church Street South, New Haven, Connecticut, 06519, United States of America
| | | | | | - Erika Linnander
- Global Health Leadership Institute, Yale University School of Public Health, 2 Church Street South, New Haven, Connecticut, 06519, United States of America
| | - Elizabeth H Bradley
- Global Health Leadership Institute, Yale University School of Public Health, 2 Church Street South, New Haven, Connecticut, 06519, United States of America
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Implementation of a multidisciplinary clinical pathway for the management of postpartum hemorrhage: a retrospective study. Int J Qual Health Care 2015; 27:459-65. [DOI: 10.1093/intqhc/mzv068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2015] [Indexed: 11/15/2022] Open
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