eRegistries: indicators for the WHO Essential Interventions for reproductive, maternal, newborn and child health

Developmental Strategy and Validation of the Midwifery Interventions Classification (MIC): A Delphi Study Protocol and Results from the Developmental Phase

This study protocol aims to describe the rationale and developmental strategy of the first study in the Italian context which aimed to define a Midwifery Interventions Classification, an evidence-based, standardized taxonomy and classification of midwifery interventions. Midwifery interventions require a specific definition, developed through a consensus-building process by stakeholders to develop the Italian taxonomy of the Midwifery Interventions Classification with the potential for international transferability, implementation, and scaling up. A multi-round Delphi study was designed between June and September 2022, and data collection is planned between February 2023 and February 2024. The developmental phase of the study is based on a literature review to select meaningful midwifery interventions from the international literature, aiming to identify an evidence-based list of midwifery interventions. This phase led to including 16 articles derived from a systematic search performed on PubMed, CINAHL, and Scopus; 164 midwifery interventions were selected from the data extraction performed on the 16 included articles. Healthcare professionals, researchers, and service users will be eligible panelists for the Delphi surveys. The protocol designed a dynamic number of consultation rounds based on the ratings and interim analysis. A nine-point Likert scoring system is designed to evaluate midwifery interventions. Attrition and attrition bias will be evaluated. The results from the study designed in this protocol will inform the development of the Italian taxonomy of the Midwifery Interventions Classification. A shared classification of midwifery interventions will support audit and quality improvement, education, and comparable data collections for research, sustaining public recognition of midwifery interventions to promote optimal maternal and newborn health.

Measures to assess quality of postnatal care: A scoping review

High quality postnatal care is key for the health and wellbeing of women after childbirth and their newborns. In 2022, the World Health Organization (WHO) published global recommendations on maternal and newborn care for a positive postnatal care experience in a new WHO PNC guideline. Evidence regarding appropriate measures to monitor implementation of postnatal care (PNC) according to the WHO PNC guideline is lacking. This scoping review aims to document the measures used to assess the quality of postnatal care and their validity. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Five electronic bibliographic databases were searched together with a grey literature search. Two reviewers independently screened and appraised identified articles. All data on PNC measures were extracted and mapped to the 2022 WHO PNC recommendations according to three categories: i) maternal care, ii) newborn care, iii) health system and health promotion interventions. We identified 62 studies providing measures aligning with the WHO PNC recommendations. For most PNC recommendations there were measures available and the highest number of recommendations were found for breastfeeding and the assessment of the newborn. No measures were found for recommendations related to sedentary behavior, criteria to be assessed before discharge, retention of staff in rural areas and use of digital communication. Measure validity assessment was described in 24 studies (39%), but methods were not standardized. Our review highlights a gap in existing PNC measures for several recommendations in the WHO PNC guideline. Assessment of the validity of PNC measures was limited. Consensus on how the quality of PNC should be measured is needed, involving a selection of priority measures and the development of new measures as appropriate.

Implementation of a Regional Standardised Model for Perinatal Electronic Medical Records

Electronic recording of newborn health information contributes to improving the quality of care. Nonetheless, there is limited evidence on the implementation of perinatal electronic medical records models. We describe the development and implementation of an electronic recording model that includes data on the health care provided to both the mother and the newborn, standardised for six hospitals of a regional health care system. The implementation process was developed in 2 stages. During stage 1, the tool was introduced in hospitals to stablish first contact with the healthcare staff. The second stage consisted in designing a new strategy to stabilise the model. Technical issues were fixed, and a new version was drawn up based on multidisciplinary agreement. Indicators to monitor implementation were measured in both stages and compared using the chi-squared test. During stage 1, nearly every newborn got its electronic medical record with an appropriate connection to the mother's data. However, certain forms that were meant to be filled in by staff were frequently neglected (completion rates: 36.7%-55.3%). In stage 2, there was a statistically significant increase in the completion rates of all these forms. As a result, a standardised discharge report was provided to every newborn at the end of stage 2. The PCR model implemented in the Region of Murcia is an innovative example of how the digitalisation and standardisation of data related to the care of healthy newborns at maternity wards is feasible across an entire network of hospitals.

Operationalising a modified Delphi study to progress quality care process nursing metrics for acute care

Background

Despite representing the largest occupational group within the healthcare workforce, evidence suggests that due to the complexity of nursing practice, nurses' contribution remains 'invisible'. Quality Care Metrics aligned to standards can offer valuable numerical information that quantify input, output and dimensions of nursing care processes in complex clinical and interprofessional milieus.

Aims and objectives

Progress an evidence-based metric system to measure the quality and clinical safety of nursing care within acute care in Ireland. The objectives were to: classify quality care process nursing metrics and corresponding indicators pertinent to acute care; reach agreement on a selected set of robust metrics and corresponding indicators; and implement the findings of the study.

Design

A modified four-round Delphi study.

Methods

The modified Delphi study integrated a four-round survey of 422 nurses, face-to-face meetings with a patient representative and key stakeholders within acute services with a final consensus meeting inclusive of a panel of 26 expert nurse clinicians.

Results

There was consensus on 11 quality care process nursing metrics and 53 corresponding indicators for the acute care setting. Despite the rating of 'critical' in the Delphi rounds, a concern was reported by participants on the subjective nature of three of the developed metrics: 'patient experience', 'patient engagement' and 'professional and ethical approach to care' based on the absence of objective measurement tools that include patient input. Conversely, this led to the conundrum for the panel of experts at the final consensus meeting who were divided in their views on objectively observing, recording and subsequent auditing of those three developed metrics in real-time clinical practice.

Conclusion

This paper describes the operationalisation of a modified Delphi technique that progressed a set of 11 quality care process metrics and 53 corresponding indicators. The challenge now is the implementation of these quality care process metrics so that nurses' contribution to patient-centred care is tangible in acute care.

Developing guideline-based key performance indicators for recurrent miscarriage care: lessons from a multi-stage consensus process with a diverse stakeholder group

BACKGROUND

Standardised care pathways tailored to women/couples who experience recurrent miscarriage are needed; however, clinical practice is inconsistent and poorly organised. In this paper, we outline our processes and experiences of developing guideline-based key performance indicators (KPIs) for recurrent miscarriage care with a diverse stakeholder group which will be used to evaluate national services. To date, such exercises have generally only involved clinicians, with the need for greater stakeholder involvement highlighted.

METHODS

Our study involved six stages: (i) identification and synthesis of recommendations for recurrent miscarriage care through a systematic review of clinical practice guidelines; (ii) a two-round modified e-Delphi survey with stakeholders to develop consensus on recommendations and outcomes; (iii) four virtual meetings to develop this consensus further; (iv) development of a list of candidate KPIs; (v) survey to achieve consensus on the final suite of KPIs and a (vi) virtual meeting to agree on the final set of KPIs. Through participatory methods, participants provided feedback on the process of KPI development.

RESULTS

From an initial list of 373 recommendations and 14 outcomes, 110 indicators were prioritised for inclusion in the final suite of KPIs: (i) structure of care (n = 20); (ii) counselling and supportive care (n = 7); (iii) investigations (n = 30); treatment (n = 34); outcomes (n = 19). Participants' feedback on the process comprised three main themes: accessibility, richness in diversity, streamlining the development process.

CONCLUSIONS

It is important and feasible to develop guideline-based KPIs with a diverse stakeholder group. One hundred and ten KPIs were prioritised for inclusion in a suite of guideline-based KPIs for recurrent miscarriage care. Insights into our experiences may help others undertaking similar projects, particularly those undertaken in the absence of a clinical guideline and/or involving a range of stakeholders.

Collaborative identification and prioritisation of mental health nursing care process metrics and indicators: a Delphi consensus study

BACKGROUND

The Irish Office of Nursing & Midwifery Services Director (ONMSD) commissioned the development an updated suite of mental health nursing metrics and indicators for implementation in Irish mental health clinical settings. While measuring care processes does offer the potential to improve care quality, the choice of which mental health nursing metrics to measure presents a significant challenge, both in Ireland and internationally. The provision of safe and high-quality mental health nursing care stems from nurses' expertise, skills and overall capacity to provide recovery focused care across a range of health care settings. Accordingly, efforts to measure what mental health nurses do depends on the identification of those care processes that contribute to mental health nursing practice. This paper reports on the identification, development and prioritisation of a national suite of Quality Care Metrics (QCM), along with their associated indicators, for mental health nursing care processes in Ireland.

METHODS

The study was undertaken over four phases; i) a systematic literature review to identify mental health care process metrics and their associated indicators of measurement; ii) a two-round, online Delphi survey of mental health nurses to develop consensus on the suit of mental health nursing care process metrics; iii) a two-round online Delphi survey of mental health nurses to develop consensus on the indicators to be used to measure the agreed metrics; and iv) a face-to-face consensus meeting with mental health nurses and service user representatives to develop consensus on the final suite of metrics and indicators.

RESULTS

Following these four phases 9 metrics and their 71 associated indicators were agreed for inclusion in the final suite of Mental Health Nursing QCM. These metrics are applicable across the life span and the range of mental health nursing health care settings.

CONCLUSION

The development of this suite of Mental Health Nursing QCM and their indicators represents an opportunity for the measurement of safe and high-quality mental health nursing care for application in Ireland and internationally. This initial development of metrics and indicators should be followed by a rigorous baseline review of QCM uptake and implementation amongst mental health nurses as part of an ongoing evaluation.

Maternity Continuum Care Completion and Its Associated Factors in Northwest Ethiopia

BACKGROUND

Continuum care is a basic package approach for women to receive essential services throughout pregnancy, childbirth, and postpartum, and it is critical for women and their infants' survival and well-being. Although it is an effective strategy for improving maternal and child health, it has not been implemented adequately in less developed countries, primarily in sub-Saharan Africa, including Ethiopia, where 55% of women have been dropped out from the continuum of care. Therefore, this study is aimed at assessing maternity continuum care completion and its associated factors within northwest Ethiopia, 2020.

MATERIALS AND METHODS

A community-based cross-sectional study design was considered among 504 women from March 10 to March 30, 2020, using pretested and structured questionnaires administered via face-to-face interviews. To select study participants, a simple random sampling technique was used. Data were coded, checked, and entered into EpiData software (V. 4.2), then transferred to SPSS (V. 25) for further analysis. A bivariable analysis with 95% CI was performed, and variables with P 0.25 during binary logistic regression were entered into a multivariable analysis to assess predictors' independent effect.

RESULTS

About 177 (37.6%) women completed maternal continuum care. Women with secondary education and above (AOR = 2.75, 95% CI 1.42-5.32), urban residence (AOR = 2.45, 95% CI 1.35-4.45), using ambulance transport (AOR = 3.96, 95% CI 2.19-7.19), mass media exposure (AOR = 3.64, 95% CI 2.02-6.56), and distance from health facilities (AOR = 3.22, 95% CI 1.84-5.63) showed significant positive associations with completion of maternity continuum care.

CONCLUSION

However, a higher proportion of mothers completed the continuum of maternity care in the district than Ethiopian Demographic and Health Survey 2016 (9.1%); further interventions are compulsory to reach the acceptable level. Hence, comprehensive awareness-raising, education, and promotion activities at the community and health facility levels and empowering women in health care and decision-making backing to expand the completion of maternity continuum of care are necessary.

National and subnational coverage and inequalities in reproductive, maternal, newborn, child, and sanitary health interventions in Ecuador: a comparative study between 1994 and 2012

BACKGROUND

Latin America (LA) has experienced constant economic and political crises that coincide with periods of greater inequality. Between 1996 and 2007 Ecuador went through one of the greatest political and socio-economic crises in Latin America, a product of neo-liberal economic growth strategies. Between 2007 and 2012 it regained political stability, promoted redistributive policies, and initiated greater social spending. To understand the possible influence on the political and economic context, we analyzed the coverage and inequalities in five Reproductive, Maternal, and Child Health (RMNCH) and two water and sanitation interventions using survey data from a broad time window (1994-2012), at a national and subnational level.

METHODS

The series cross-sectional study used data from four representative national health surveys (1994, 1999, 2004 and 2012). Coverage of RMNCH and sanitary interventions were stratified by wealth quintiles (as a measure of the socio-economic level), urban-rural residence and the coverage for each province was mapped. Mean difference, Theil index and Variance-weighted least squares regression were calculated to indicate subnational and temporal changes.

RESULTS

From 1994 to 2004, Ecuador evidenced large inequalities whose reduction becomes more evident in 2012. Coverage in RMNCH health service-related interventions showed a rather unequal distribution among the socioeconomic status and across provinces in 1994 and 2004, compared to 2012. Sanitary interventions on the contrary, showed the most unequal interventions, and failed to improve or even worsened in several provinces. While there is a temporary improvement also at the subnational level, in 2012 several provinces maintain low levels of coverage.

CONCLUSIONS

The remarkable reduction of inequalities in coverage of RMNCH interventions in 2012 clearly coincides with periods of regained political stability, promoted redistributive policies, and greater social spending, different from the former neo-liberal reforms which is consistent with observations made in other Latin American countries. Territorial heterogeneity and great inequalities specially related with sanitation interventions persists. It is necessary to obtain high quality information with sharper geographic desegregation that allows to identify and understand local changes over time. This would help to prioritize intervention strategies, introduce multisectoral policies and investments that support local governments.

Coverage of the WHO's four essential elements of newborn care and their association with neonatal survival in southern Nepal

Background

Despite recent improvements in child survival, neonatal mortality continues to decline at a slower rate and now represents 47% of under-five deaths globally. The World Health Organization developed core indicators to better monitor the quality of maternal and newborn health services. One such indicator for newborn health is “the proportion of newborns who received all four elements of essential care”. The four elements are immediate and thorough drying, skin to skin contact, delayed cord clamping, and early initiation of breastfeeding. Although there is existing evidence demonstrating an association with decreased neonatal mortality for each element individually, the cumulative impact has not yet been examined.

Methods

This analysis uses data from a randomized trial to examine the impact of sunflower versus mustard seed oil massage on neonatal mortality and morbidity in the Sarlahi district in Southern Nepal from 2010 to 2017. The proportion of newborn infants receiving an intervention was the exposure and neonatal mortality was the outcome in this analysis. Neonatal mortality was defined as a death between three hours and less than 28 days of age. Associations between neonatal mortality and the essential elements were estimated by Cox proportion hazards models. The hazard ratios and corresponding 95% confidence intervals were reported.

Results

28,121 mother-infant pairs and 753 neonatal deaths were included. The percent receiving the individual elements ranged from 19.5% (skin to skin contact) to 68.2% (delayed cord clamping). The majority of infants received one or two of the elements of essential care, with less than 1% receiving all four. Skin to skin contact and early initiation of breastfeeding were associated with lower risk of neonatal mortality (aHR = 0.64 [0.51, 0.81] and aHR = 0.72 [0.60, 0.87], respectively). The risk of mortality declined as the number of elements received increased; receipt of one element compared to zero was associated with a nearly 50% reduction in risk of mortality and receipt of all four elements resulted in a 72% decrease in risk of mortality.

Conclusions

The receipt of one or more of the four essential elements of newborn care was associated with improved neonatal survival. The more elements of care received, the more survival improved.

A missed opportunity: birth registration coverage is lagging behind Bacillus Calmette-Guérin (BCG) immunization coverage and maternal health services utilization in low- and lower middle-income countries

BACKGROUND

Civil registration and vital statistics (CRVS) systems lay the foundation for good governance by increasing the effectiveness and delivery of public services, providing vital statistics for the planning and monitoring of national development, and protecting fundamental human rights. Birth registration provides legal rights and facilitates access to essential public services such as health care and education. However, more than 110 low- and middle-income countries (LMICs) have deficient CRVS systems, and national birth registration rates continue to fall behind childhood immunization rates. Using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data in 72 LMICs, the objectives are to (a) explore the status of birth registration, routine childhood immunization, and maternal health services utilization; (b) analyze indicators of birth registration, routine childhood immunization, and maternal health services utilization; and (c) identify missed opportunities for strengthening birth registration systems in countries with strong childhood immunization and maternal health services by measuring the absolute differences between the birth registration rates and these childhood and maternal health service indicators.

METHODS

We constructed a database using DHS and MICS data from 2000 to 2017, containing information on birth registration, immunization coverage, and maternal health service indicators. Seventy-three countries including 34 low-income countries and 38 lower middle-income countries were included in this exploratory analysis.

RESULTS

Among the 14 countries with disparity between birth registration and BCG vaccination of more than 50%, nine were from sub-Saharan Africa (Tanzania, Uganda, Gambia, Mozambique, Djibouti, Eswatini, Zambia, Democratic Republic of Congo, Ghana), two were from South Asia (Bangladesh, Nepal), one from East Asia and the Pacific (Vanuatu) one from Latin America and the Caribbean (Bolivia), and one from Europe and Central Asia (Moldova). Countries with a 50% or above absolute difference between birth registration and antenatal care coverage include Democratic Republic of Congo, Gambia, Mozambique, Nepal, Tanzania, and Uganda, in low-income countries. Among lower middle-income countries, this includes Eswatini, Ghana, Moldova, Timor-Leste, Vanuatu, and Zambia. Countries with a 50% or above absolute difference between birth registration and facility delivery care coverage include Democratic Republic of Congo, Djibouti, Moldova, and Zambia.

CONCLUSION

The gap between birth registration and immunization coverage in low- and lower middle-income countries suggests the potential for leveraging immunization programs to increase birth registration rates. Engaging health providers during the antenatal, delivery, and postpartum periods to increase birth registration may be a useful strategy in countries with access to skilled providers.

eRegTime, Efficiency of Health Information Management Using an Electronic Registry for Maternal and Child Health: Protocol for a Time-Motion Study in a Cluster Randomized Trial

BACKGROUND

Paper-based routine health information systems often require repetitive data entry. In the West Bank, the primary health care system for maternal and child health was entirely paper-based, with care providers spending considerable amounts of time maintaining multiple files and client registers. As part of the phased national implementation of an electronic health information system, some of the primary health care clinics are now using an electronic registry (eRegistry) for maternal and child health. The eRegistry consists of client-level data entered by care providers at the point-of-care and supports several digital health interventions that are triggered by the documented clinical data, including guideline-based clinical decision support and automated public health reports.

OBJECTIVE

The aim of the eRegTime study is to investigate whether the use of the eRegistry leads to changes in time-efficiency in health information management by the care providers, compared with the paper-based systems.

METHODS

This is a substudy in a cluster randomized controlled trial (the eRegQual study) and uses the time-motion observational study design. The primary outcome is the time spent on health information management for antenatal care, informed and defined by workflow mapping in the clinics. We performed sample size estimations to enable the detection of a 25% change in time-efficiency with a 90% power using an intracluster correlation coefficient of 0.1 and an alpha of .05. We observed care providers for full workdays in 24 randomly selected primary health care clinics-12 using the eRegistry and 12 still using paper. Linear mixed effects models will be used to compare the time spent on health information management per client per care provider.

RESULTS

Although the objective of the eRegQual study is to assess the effectiveness of the eRegistry in improving quality of antenatal care, the results of the eRegTime study will contribute to process evaluation, supplementing the findings of the larger trial.

CONCLUSIONS

Electronic health tools are expected to reduce workload for the care providers and thus improve efficiency of clinical work. To achieve these benefits, the implementation of such systems requires both integration with existing workflows and the creation of new workflows. Studies assessing the time-efficiency of electronic health information systems can inform policy decisions for implementations in resource-limited low- and middle-income settings.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13653.

A guidance framework to aid in the selection of nursing and midwifery care process metrics and indicators

AIM

To describe the development of a guidance framework to assist nurses and midwives in selecting nursing and midwifery care process metrics and indicators for use in practice.

BACKGROUND

Process metrics are measures of care provision activities by nurses and midwives.

METHODS

Phase 1 was a rapid review assessment of the literature conducted to identify an initial framework. Six electronic databases were searched with Google Scholar and reference tracking performed. Phase 2 was expert review of the developing framework by nursing and midwifery experts in practice, academia and an international expert in quality care metrics.

RESULTS

The literature assessment yielded 28 papers with 59 metric attributes identified. From this, a six-domain framework was developed. Following expert review, the framework was reduced to four domains: "Process Focused," "Important," "Operational" and "Feasible."

CONCLUSIONS

This is the first framework specifically to guide nurses and midwives in selecting nursing and midwifery process metrics and indicators.

Identifying and prioritising midwifery care process metrics and indicators: a Delphi survey and stakeholder consensus process

Background

Measuring care processes is an important component of any effort to improve care quality, however knowing the appropriate metrics to measure is a challenge both in Ireland and other countries. Quality of midwifery care depends on the expert knowledge of the midwife and her/his contribution to women and their babies’ safety in the healthcare environment. Therefore midwives need to be able to clearly articulate and measure what it is that they do, the dimensions of their professional practice frequently referred to as midwifery care processes. The objective of this paper is to report on the development and prioritisation of a national suite of Quality Care Metrics (QCM), and their associated indicators, for midwifery care processes in Ireland.

Methods

The study involved four discrete, yet complimentary, phases; i) a systematic literature review to identify midwifery care process metrics and their associated measurement indicators; ii) a two-round, online Delphi survey of midwives to develop consensus on the set of midwifery care process metrics to be measured; iii) a two-round online Delphi survey of midwives to develop consensus on the indicators that will be used to measure prioritised metrics; and iv) a face-to-face consensus meeting with midwives to review the findings and achieve consensus on the final suite of metrics and indicators.

Results

Following the consensus meeting, 18 metrics and 93 indicators were prioritised for inclusion in the suite of QCM Midwifery Metrics. These metrics span the pregnancy, birth and postpartum periods.

Conclusion

The development of this suite of process metrics and indicators for midwifery care provides an opportunity for measuring the safety and quality of midwifery care in Ireland and for adapting internationally. This initial work should be followed by a rigorous evaluation of the impact of the new suite of metrics on midwifery care processes.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2346-z) contains supplementary material, which is available to authorized users.

Role of Usual Healthcare Combined with Telemedicine in the Management of High-Risk Pregnancy in Hangzhou, China

Background

Maternal health is an important part of basic public health services in China's medical reform. Effective management is an important guarantee of maternal health. Telemedicine has been widely used in maternal health management.

Objective

This study explores the role of usual healthcare combined with telemedicine in the management of high-risk pregnancy.

Methods

The study was a retrospective. Data were obtained from Hangzhou Maternity Hospital between October 2012 and September 2016, including 93465 pregnant women who were in usual high-risk pregnancy management (usual group) and 134884 pregnant women who were in telemedicine combined with usual high-risk pregnancy management (telemedicine group). The differences in high-risk scores and pregnancy outcomes between the usual and the telemedicine groups were compared.

Results

The high-risk factors were analyzed, and the results showed that the first fixed high-risk factor was scar uterus and the first dynamic high-risk factor was hepatitis B. Comparing the data of two groups, the number of prenatal visits increased significantly in the telemedicine group (p value <0.05). Although the critical proportion of high-risk women was 2.13% in the usual group and 5.88% in the telemedicine group, respectively (p value <0.01), maternal mortality decreased in the telemedicine group (p value <0.05).

Conclusion

The combination of telemedicine and usual healthcare can urge the pregnant women to carry out antenatal visits on time, which is one of the important factors to improve the outcome of high-risk pregnancy.

Developing measures for WHO recommendations on antenatal care for a positive pregnancy experience: a conceptual framework and scoping review

OBJECTIVES

In response to the newest WHO recommendations on routine antenatal care (ANC) for pregnant women and adolescent girls, this paper identifies the literature on existing ANC measures, presents a conceptual framework for quality ANC, maps existing measures to specific WHO recommendations, identifies gaps where new measures are needed to monitor the implementation and impact of routine ANC and prioritises measures for capture.

METHODS

We conducted searches in four databases and five websites. Searches and application of inclusion/exclusion criteria followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow approach for scoping reviews. Data were extracted on measure information, methodology, methodological work and implementation. We adapted and refined a conceptual framework for routine ANC based on these measures.

RESULTS

This scoping review uncovered 58 resources describing 46 existing measures that align with WHO recommendations and good clinical practices for ANC. Of the 42 WHO-recommended ANC interventions and four good clinical practices included in this scoping review, only 14 WHO-recommended interventions and three established good clinical practices could potentially be measured immediately using existing measures. Recommendations addressing the integration of ANC with allied fields are likelier to have existing measures than recommendations that focus on maternal health. When mapped to our conceptual framework, existing measures prioritise content of care and health systems; measures for girls' and women's experiences of care are notably lacking. Available data sources for non-existent measures are currently limited.

CONCLUSION

Our research updates prior efforts to develop comprehensive measures of quality ANC and raises awareness of the need to better assess experiences of ANC. Given the inadequate number and distribution of existing ANC measures across the quality of care conceptual framework domains, new standardised measures are required to assess quality of routine ANC. Girls' and women's voices deserve greater acknowledgement when measuring the quality and delivery of ANC.

Development of a suite of metrics and indicators for children's nursing using consensus methodology

AIM AND OBJECTIVES

To develop a suite of metrics and indicators to measure the quality of children's nursing care processes. The objectives were to identify available metrics and indicators and to develop consensus on the metrics and indicators to be measured.

BACKGROUND

The Office of Nursing and Midwifery Services Director, Health Service Executive, in Ireland established seven workstreams aligned to the following care areas: acute, older persons, children's, mental health, intellectual disability, public health nursing and midwifery.

DESIGN

A comprehensive design included stakeholder consultation and a survey with embedded open-ended questions.

METHODS

A two-round online Delphi survey was conducted to identify metrics to be measured in practice, followed by a two-round online Delphi survey to identify the associated indicators for these metrics. A face-to-face consensus meeting was held with key stakeholders to review the findings and build consensus on the final metrics and indicators for use. A STROBE checklist was completed.

RESULTS

A suite of eight nursing quality care process metrics and 67 associated process indicators was developed for children's nursing.

CONCLUSIONS

By creating a national suite of metrics and indicators, more robust measurement and monitoring of nursing care processes can be achieved. This will enable the provision of evidence for any local and/or national level changes to policy and practice to enhance care delivery.

RELEVANCE TO CLINICAL PRACTICE

The roll-out of the metrics and indicators in clinical practice has commenced. This national suite of metrics and indicators will ensure that a robust system of measurement for improvement is in place to provide assurance to Directors of Nursing of the quality of nursing care being provided to children and their families. It supports the value of nursing sensitive data to inform change and improvement in healthcare delivery and to demonstrate the contribution of the nursing workforce to safe patient care.

Comparing individual-level clinical data from antenatal records with routine health information systems indicators for antenatal care in the West Bank: A cross-sectional study

BACKGROUND

In most low- and middle-income settings, national aggregate health data is the most consistently available source for policy-making and international comparisons. In the West Bank, the paper-based health information system with manual aggregations is transitioning to an individual-level data eRegistry for maternal and child health at the point-of-care. The aim of this study was to explore beforehand how routine health information systems indicators for antenatal care can change with the introduction of the eRegistry.

METHODS

Data were collected from clinical antenatal paper records of pregnancy enrollments for 2015 from 17 primary healthcare clinics, selected by probability sampling from five districts in the West Bank. We used the individual-level data from clinical records to generate routinely reported health systems indicators. We weighted the data to produce population-level estimates, and compared these indicators with aggregate routine health information systems reports.

RESULTS

Antenatal anemia screening at 36 weeks was 20% according to the clinical records data, compared to 52% in the routine reports. The clinical records data showed considerably higher incidences of key maternal conditions compared to the routine reports, including fundal height discrepancy (20% vs. 0.01%); Rh-negative blood group (6.8% vs. 1.4%); anemia with hemoglobin<9.5 g/dl (6% vs. 0.6%); and malpresentation at term (1.3% vs. 0.03%). Only about a sixth of cases with these conditions were referred according to guidelines to designated referral clinics.

CONCLUSIONS

Differences between indicators from the clinical records data and routine health information systems reports can be attributed to human error, inconsistent denominators, and complexities of data processes. Key health systems indicators were prone to underestimations since their registration was dependent on referral of pregnant women. With a transition to individual-level data, as in the eRegistry under implementation, the public health authorities will be able to generate reliable health systems indicators reflective of the population's health status.

Twin Pregnancy in Brazil: A Profile Analysis Exploring Population Information from the National Birth E-Registry on Live Births

Birth records as SINASC (Brazilian Live Birth Information System) are highlighted in uncommon conditions such as twin pregnancy whose prevalence rarely exceeds 2 to 3% of the total number of births. The objective of this study was to assess the prevalence of twin pregnancies in Brazil and their maternal and perinatal characteristics using data from the national birth e-Registry. All births in Brazil from 2011 to 2014 were assessed. Prevalence of twin pregnancies per region was assessed and correlated with the Human Development Index (HDI). Sociodemographic and obstetric factors and main perinatal outcomes were assessed for the first and second twin, in comparison to singletons, and the second twin compared to the first twin, with PR and 95%CI. A multiple logistic regression analysis was conducted to identify factors independently associated with a low 5-minute Apgar score in twin pregnancies. Twin pregnancy occurred in 1.13% in Brazil, with a higher prevalence in regions with a higher HDI. It was associated with a complete higher level of education (22.9% versus 16.3% for singles) and maternal age > 35 years (17.5% versus 11.4% for singles). Preterm birth <32 weeks (prevalence ratio-PR 12.13 [11.93 – 12.33]), low birth weight (PR 17.8 [17.6-18.0] for the first and PR 20.1 [19.8-20.3] for the second twin), and low Apgar score (PR 2.9 [2.8-3.0] for the first and PR 2.7 [2.6-2.8] for the second twin) were the most important perinatal outcomes associated with twin pregnancies. A 5-minute Apgar score < 7 among twins was associated with inadequate prenatal care, extreme preterm birth, vaginal delivery, intrapartum cesarean, and combined delivery. Twin pregnancy in Brazil is associated with worse perinatal outcomes, especially for the second twin.

Measurement approaches in continuum of care for maternal health: a critical interpretive synthesis of evidence from LMICs and its implications for the South African context

Background

Global strategies recommend a continuum of care for maternal health to improve outcomes and access to care in low and middle income countries (LMICs). South Africa has already set priority interventions along the continuum of care for maternal health, and mandated their implementation at the district health level. However, the approach for monitoring access to this continuum of care has not yet been defined. This review assessed measurement approaches in continuum of care for maternal health among LMICs and their implications for the South African context.

Methods

We conducted a critical interpretive synthesis of quantitative and qualitative research sourced from Academic Search Complete (EBSCO), MEDLINE (Pubmed), Cambridge Journals Online, Credo Reference and Science Direct. We selected 20 out of 118 articles into the analysis, following a rigorous quality appraisal and relevance assessment. The outcomes of the synthesis were new constructs for the measurement of continuum of care for maternal health, derived from the existing knowledge gaps.

Results

We learned that coverage was the main approach for measuring and monitoring the continuum of care for maternal health in LMICs. The measure of effective coverage was also used to integrate quality into coverage of care. Like coverage, there was no uniform definition of effective coverage, and we observed gaps in the measurement of multiple dimensions of quality. From the evidence, we derived a new construct called adequacy that incorporated timeliness of care, coverage, and the complex nature of quality. We described the implications of adequacy to the measurement of the continuum of care for maternal health in South Africa.

Conclusions

Critical interpretive synthesis allowed new understandings of measurement of the continuum of care for maternal health in South Africa. The new construct of adequacy can be the basis of a new measure of access to the continuum of care for maternal health. Although adequacy conceptualizes a more holistic approach, more research is needed to derive its indicators and metrics using South African data sources.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3278-4) contains supplementary material, which is available to authorized users.

Classification of causes and associated conditions for stillbirths and neonatal deaths

Accurate and consistent classification of causes and associated conditions for perinatal deaths is essential to inform strategies to reduce the five million which occur globally each year. With the majority of deaths occurring in low- and middle-income countries (LMICs), their needs must be prioritised. The aim of this paper is to review the classification of perinatal death, the contemporary classification systems including the World Health Organization's International Classification of Diseases - Perinatal Mortality (ICD-PM), and next steps. During the period from 2009 to 2014, a total of 81 new or modified classification systems were identified with the majority developed in high-income countries (HICs). Structure, definitions and rules and therefore data on causes vary widely and implementation is suboptimal. Whereas system testing is limited, none appears ideal. Several systems result in a high proportion of unexplained stillbirths, prompting HICs to use more detailed systems that require data unavailable in low-income countries. Some systems appear to perform well across these different settings. ICD-PM addresses some shortcomings of ICD-10 for perinatal deaths, but important limitations remain, especially for stillbirths. A global approach to classification is needed and seems feasible. The new ICD-PM system is an important step forward and improvements will be enhanced by wide-scale use and evaluation. Implementation requires national-level support and dedicated resources. Future research should focus on implementation strategies and evaluation methods, defining placental pathologies, and ways to engage parents in the process.

eRegistries: governance for electronic maternal and child health registries

BACKGROUND

The limited availability of maternal and child health data has limited progress in reducing mortality and morbidity among pregnant women and children. Global health agencies, leaders, and funders are prioritizing strategies that focus on acquiring high quality health data. Electronic maternal and child health registries (eRegistries) offer a systematic data collection and management approach that can serve as an entry point for preventive, curative and promotive health services. Due to the highly sensitive nature of reproductive health information, careful consideration must be accorded to privacy, access, and data security. In the third paper of the eRegistries Series, we report on the current landscape of ethical and legal governance for maternal and child health registries in developing countries.

METHODS

This research utilizes findings from two web-based surveys, completed in 2015 that targeted public health officials and health care providers in 76 countries with high global maternal and child mortality burden. A sample of 298 public health officials from 64 countries and 490 health care providers from 59 countries completed the online survey. Based on formative research in the development of the eRegistries Governance Guidance Toolkit, the surveys were designed to investigate topics related to maternal and child health registries including ethical and legal issues.

RESULTS

According to survey respondents, the prevailing legal landscape is characterized by inadequate data security safeguards and weak support for core privacy principles. Respondents from the majority of countries indicated that health information from medical records is typically protected by legislation although legislation dealing specifically or comprehensively with data privacy may not be in place. Health care provider trust in the privacy of health data at their own facilities is associated with the presence of security safeguards.

CONCLUSION

Addressing legal requirements and ensuring that privacy and data security of women's and children's health information is protected is an ethical responsibility that must not be ignored or postponed, particularly where the need is greatest. Not only are the potential harm and unintended consequences of inaction serious for individuals, but they could impact public trust in health registries leading to decreased participation and compromised data integrity.