Guest Editors’ Choice
DOI: 10.1111/1471-0528.13011 www.bjog.org
Guest Editors’ Choice
Improving the quality of care for maternal and newborn health is crucial if health outcomes for mothers and babies are to continue to improve. This will require a renewed global focus. Estimates published in May 2014 show that, globally, an estimated 289 000 women die during pregnancy, childbirth or in the postnatal period, 2.6 million babies are stillborn and 3 million babies die within 1 month of birth.1,2 The majority of these happen in low- and middle-income settings, are preventable, and occur during labour and childbirth and in the first week after birth. Ensuring quality care is provided to every mother, fetus and newborn during this period is critical for maternal and newborn survival. Monitoring of progress towards the achievement of Millennium Development Goals (MDGs) has focused on coverage of key interventions; for example, antenatal and postnatal care attendance rates and skilled birth attendance rates (a proxy measure for MDGs). Although such coverage rates have been increasing rapidly in many settings,3 it is widely acknowledged that the quality of care provided for mothers and babies falls short of current evidence-based practice and is, in many cases, not ‘woman and baby friendly’. Indeed, it could be considered ‘substandard’ in many settings. Uptake (and coverage) of care and quality of care are closely linked; there are numerous examples in the literature describing where and how poor quality of care has stopped women from accessing healthcare services, even where these were available, close by and affordable. A variety of methods to improve quality of care have been successfully used in maternal and newborn health. These include: conducting mortality audit or review for maternal and perinatal deaths (stillbirths and newborn deaths), review of cases of ‘near-miss’ or severe acute maternal morbidity (SAMM) and standards-based (or clinical) audit.4
2
Documented experience of the use of these approaches, methodologies and tools suggests that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools generally depends on the available resources and healthcare system. Leadership and developing a ‘culture of quality’ are considered to be important prerequisites for (or part of) implementation of quality improvement methodology. This supplement highlights the experiences of leaders and colleagues across the globe with regard to introducing and implementing different types of audit to improve quality of maternal and newborn care. Mahmud et al., Hinton et al., and Flenady et al. highlight the importance of understanding the experiences of women and their families and how this should inform what we mean by ‘quality’. Heiby et al. remind us of the need for improving healthcare processes and adopting evidence-based guidelines. Several country case studies describe how maternal death audit (Moldova, Cameroon, Nigeria) and/or a confidential enquiry into maternal deaths (Kerala State in India, the Republic of South Africa, Malaysia) can be implemented at regional or national level. The authors give a ‘real life’ account of not only how difficult this can be but also how this careful and honest type of evaluation of care received by women who died helps to identify the specific areas of care that are substandard and require action. These country case studies illustrate the importance of support for change at all levels in the health system, a multidisciplinary approach and dedicated leadership. The new cause classification for maternal deaths (International Classification of Diseases; Maternal Mortality [ICD-MM]) was published in 2012 by WHO, Geneva.5 Ameh et al. and Owalabi et al. show how this can be applied in practice and demonstrate the need
for standardisation of international terminology including for ‘underlying cause of death’ and ‘contributing factors’. Perinatal and stillbirth audit is still less widely practiced. Buchmann explains that this is a very powerful tool and should be an essential part of all obstetric services and the case studies from the Republic of South Africa (Rhoda) and Moldova (Stratulat) show how this can be done. Aminu et al. conducted a systematic review highlighting the need for a simple and comprehensive classification system to be able to assign cause of death in case of stillbirth as well as a need for much better collection of data that will allow aggregation and comparison across various settings. Finally, there are some excellent examples from Mali, Niger and Ghana showing how the quality of care can be improved using standards-based audit. Poor quality is often a function of weak health systems and processes or problems in implementation generally rather than the fault of individuals. Audit can be used to identify which areas of care require strengthening. This requires that a culture of improvement and solutions is developed rather than a culture of blame. With new classification systems developed for causes of and associated factors for maternal death, and under development for stillbirth, data collection tools should be adapted to ensure that the quality of data collected is also improved. These data can be more effectively analysed and used. Healthcare providers will need to be supported to use new classification systems and to collect and use data to inform their practice. Support is also needed at central government level to enable further scale-up of audit. Currently, the emphasis has largely been on process evaluation. More research is needed to assess the impact of interventions to improve quality of care. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Guest Editor’s Choice
References 1 WHO, UNICEF, UNFPA, The World Bank, the United Nations Population Division. Trends in Maternal Mortality 1990 to 2013: Estimates by the WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014. [www.who.int/reproductiveheal th/publications/monitoring/maternal-mortality2013/en/]. Accessed 3 May 2014. 2 The Lancet. Every Newborn May 2014 [www.thelancet.com/series/everynewborn]. Accessed 27 May 2014. 3 WHO. World Health Statistics 2013. Geneva: World Health Organization; 2013.
[www.who.int/gho/publications/world_health_ statistics/2013/en/]. Accessed 3 May 2014. 4 Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Reprod Contracept Obstet Gynecol 2011;114:4–9. 5 World Health Organization. The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-MM. Geneva: World Health Organization; 2012. [www.who.int/reproductivehealth/publi cations/monitoring/9789241548458/en/]. Accessed 15 May 2014.
ª 2014 Royal College of Obstetricians and Gynaecologists
Nynke van den Broek,a Gwyneth Lewis,b & Matthews Mathaic a Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine; bInstitute of Women’s Health, University College London; cDepartment of Maternal, Newborn, Child & Adolescent Health, Focal Point – Maternal & Perinatal Health, World Health Organization
3
DOI: 10.1111/1471-0528.13011 www.bjog.org
Guest Editors’ Choice
Improving the quality of care for maternal and newborn health is crucial if health outcomes for mothers and babies are to continue to improve. This will require a renewed global focus. Estimates published in May 2014 show that, globally, an estimated 289 000 women die during pregnancy, childbirth or in the postnatal period, 2.6 million babies are stillborn and 3 million babies die within 1 month of birth.1,2 The majority of these happen in low- and middle-income settings, are preventable, and occur during labour and childbirth and in the first week after birth. Ensuring quality care is provided to every mother, fetus and newborn during this period is critical for maternal and newborn survival. Monitoring of progress towards the achievement of Millennium Development Goals (MDGs) has focused on coverage of key interventions; for example, antenatal and postnatal care attendance rates and skilled birth attendance rates (a proxy measure for MDGs). Although such coverage rates have been increasing rapidly in many settings,3 it is widely acknowledged that the quality of care provided for mothers and babies falls short of current evidence-based practice and is, in many cases, not ‘woman and baby friendly’. Indeed, it could be considered ‘substandard’ in many settings. Uptake (and coverage) of care and quality of care are closely linked; there are numerous examples in the literature describing where and how poor quality of care has stopped women from accessing healthcare services, even where these were available, close by and affordable. A variety of methods to improve quality of care have been successfully used in maternal and newborn health. These include: conducting mortality audit or review for maternal and perinatal deaths (stillbirths and newborn deaths), review of cases of ‘near-miss’ or severe acute maternal morbidity (SAMM) and standards-based (or clinical) audit.4
2
Documented experience of the use of these approaches, methodologies and tools suggests that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools generally depends on the available resources and healthcare system. Leadership and developing a ‘culture of quality’ are considered to be important prerequisites for (or part of) implementation of quality improvement methodology. This supplement highlights the experiences of leaders and colleagues across the globe with regard to introducing and implementing different types of audit to improve quality of maternal and newborn care. Mahmud et al., Hinton et al., and Flenady et al. highlight the importance of understanding the experiences of women and their families and how this should inform what we mean by ‘quality’. Heiby et al. remind us of the need for improving healthcare processes and adopting evidence-based guidelines. Several country case studies describe how maternal death audit (Moldova, Cameroon, Nigeria) and/or a confidential enquiry into maternal deaths (Kerala State in India, the Republic of South Africa, Malaysia) can be implemented at regional or national level. The authors give a ‘real life’ account of not only how difficult this can be but also how this careful and honest type of evaluation of care received by women who died helps to identify the specific areas of care that are substandard and require action. These country case studies illustrate the importance of support for change at all levels in the health system, a multidisciplinary approach and dedicated leadership. The new cause classification for maternal deaths (International Classification of Diseases; Maternal Mortality [ICD-MM]) was published in 2012 by WHO, Geneva.5 Ameh et al. and Owalabi et al. show how this can be applied in practice and demonstrate the need
for standardisation of international terminology including for ‘underlying cause of death’ and ‘contributing factors’. Perinatal and stillbirth audit is still less widely practiced. Buchmann explains that this is a very powerful tool and should be an essential part of all obstetric services and the case studies from the Republic of South Africa (Rhoda) and Moldova (Stratulat) show how this can be done. Aminu et al. conducted a systematic review highlighting the need for a simple and comprehensive classification system to be able to assign cause of death in case of stillbirth as well as a need for much better collection of data that will allow aggregation and comparison across various settings. Finally, there are some excellent examples from Mali, Niger and Ghana showing how the quality of care can be improved using standards-based audit. Poor quality is often a function of weak health systems and processes or problems in implementation generally rather than the fault of individuals. Audit can be used to identify which areas of care require strengthening. This requires that a culture of improvement and solutions is developed rather than a culture of blame. With new classification systems developed for causes of and associated factors for maternal death, and under development for stillbirth, data collection tools should be adapted to ensure that the quality of data collected is also improved. These data can be more effectively analysed and used. Healthcare providers will need to be supported to use new classification systems and to collect and use data to inform their practice. Support is also needed at central government level to enable further scale-up of audit. Currently, the emphasis has largely been on process evaluation. More research is needed to assess the impact of interventions to improve quality of care. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Guest Editor’s Choice
References 1 WHO, UNICEF, UNFPA, The World Bank, the United Nations Population Division. Trends in Maternal Mortality 1990 to 2013: Estimates by the WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014. [www.who.int/reproductiveheal th/publications/monitoring/maternal-mortality2013/en/]. Accessed 3 May 2014. 2 The Lancet. Every Newborn May 2014 [www.thelancet.com/series/everynewborn]. Accessed 27 May 2014. 3 WHO. World Health Statistics 2013. Geneva: World Health Organization; 2013.
[www.who.int/gho/publications/world_health_ statistics/2013/en/]. Accessed 3 May 2014. 4 Raven J, Hofman J, Adegoke A, van den Broek N. Methodology and tools for quality improvement in maternal and newborn health care. Int J Reprod Contracept Obstet Gynecol 2011;114:4–9. 5 World Health Organization. The WHO application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD-MM. Geneva: World Health Organization; 2012. [www.who.int/reproductivehealth/publi cations/monitoring/9789241548458/en/]. Accessed 15 May 2014.
ª 2014 Royal College of Obstetricians and Gynaecologists
Nynke van den Broek,a Gwyneth Lewis,b & Matthews Mathaic a Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine; bInstitute of Women’s Health, University College London; cDepartment of Maternal, Newborn, Child & Adolescent Health, Focal Point – Maternal & Perinatal Health, World Health Organization
3
