Title:

ZFF comments on our title:

Assessment of Capability of Three Selected ZFF-PLGP-engaged Public Hospitals in Giving Quality Maternal Care Services that have Impact on Maternal Death Reduction

Good research title though “capability” and “impact on Maternal Death reduction” may be removed

Assessment of Three-Selected ZFF-PLGP-engaged Public Hospitals in Providing Quality Maternal Care Services

We will use what they want:

Assessment of Three-Selected ZFF-PLGP-engaged Public Hospitals in Providing Quality Maternal Care Services

ROJoson's Comments: It is not specific, but that's what they wanted. Let's still have in mind we are assessing the CAPABILITY of the sampled hospitals in providing quality maternal care services. Or not the capability? But the indicators of quality maternal care services? Are thes indicators presumed to be present as the ZFF proposal discussed the hospital scorecards and gave areas of assessment? Or both capability and indicators?

I. Availability and Accessibility of Medicines and Equipment and Other Essential Items

a. Obstetric medicines

b. Emergency medicines

c. Anesthesia

d. Ultrasound, Doppler, CTG

e. Gloves, Gown, other supplies

f. Blood

II. Obstetrical Outpatient Medical Management

a. Adequacy of the number of health professionals

b. Adherence to CPG for patients w/o co-morbidity

c. Adherence to CPG for patients with co-morbidity

d. Patient education

e. Respect for patients and cultural sensitivity

f. Referral system from catchment area

III. Obstetrical Inpatient Medical Management

a. Adequacy of the number of health professionals

b. Use of partogram

c. Adherence to CPG for patients w/o co-morbidity

d. Adherence to CPG for patients with co-morbidity

e. Patient education

IV. Patient Care Processes

a. Triage and high risk units

b. Referral system process and response time

c. Charting and endorsement

d. Supportive care

i. respect for privacy

ii. emotional support

iii. pain relief and patient comfort

iv. family friendly

e. Process for indigents

i. PhilHealth process for indigents

ii. Cost recovery program

V. Mortality and Morbidity Audit

a. Able to identify events resulting in adverse outcomes for the patient

b. Mistakes are acknowledged by health professionals and addressed

i. Medical error

ii. Adverse events

iii. Near-miss events

c. Accountability for high quality care is emphasized

d. Insights gained from discussion are identified and disseminated

Also, let's have in mind the IMPACT of the quality of maternal care services which is reduction of maternal deaths. The other group of impact of quality maternal care services may be QUALITY AND SAFE CARE or just QUALITY CARE (ti

See my notes on Quality vs Safety. timeliness, effectiveness, efficiciency, equity and patient-centeredness.

Quality vs Safety; Quality and Safety (Accreditation Canada International)

Quality is “the degree of excellence; the extent to which an organization meets clients needs and exceeds their expectations”. Key attributes of high quality healthcare systems, as defined by the Institute of Medicine (U.S.) include safety, timeliness, effectiveness, efficiency, equity and patient centeredness.

Patient safety is often considered a component of quality, thus, practices to improve patient safety improve the overall quality of care.

Quality vs Safety; Quality and Safety (Joint Commission International)

Quality and safety are inextricably linked. Quality in health care is the degree to which its processes and results meet or exceed the needs and desires of the people it serves. Those needs and desires include safety.

The Institute of Medicine defines quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Patient safety emerges as a central aim of quality. Patient safety, as defined by the World Health Organization, is the prevention of errors and adverse effects to patients that are associated with health care. Safety is what patients, families, staff and the public expect. While patient safety events may not be completely eliminated, harm to patients can be reduced, and the goal is always zero harm.

The ultimate goals are quality of care and patient safety.

ROJoson’s Summary Statements: There is a difference between quality and safe patient care. Safety is within the quality dimension. It is recommended for the safety goals to be extracted from the quality goals for emphasis reason. However, the ultimate goals should still be an alignment and integration of quality and safety in patient care.

Rationale and Significance

This project, as deduced from the ZFF TOR, is an offshoot of ZFF being concerned with the discrepancy or inconsistency of the results of the hospital scorecard it formulated in 2013 and the number of maternal deaths occurring in the hospitals.

"Indeed, some of the hospitals with highest mortalities such as Bicol Regional Training and Teaching Hospital fared well in the assessment using hospital scorecards (see Table 1).

*Number of maternal deaths

ZFF wanted to look at the hospital processes for maternal care services (and capabilities?) that will contribute to quality maternal care services which in turn will have an impact on maternal death reduction in public hospitals.

Significance of the research:

"Understanding and identifying current gaps in hospital processes for maternal health services will help the program and concerned stakeholders develop the appropriate interventions that will improve quality of obstetric care in public hospitals." (that has impact on maternal death reduction).

Are there already well-established core indicators of quality and safe maternal care services that have impact on maternal death reduction in hospitals?

Are there already well-established standards for quality and safe maternal care services that have impact on maternal death reduction in hospitals?

If there is, we use this to assess the 3-selected hospitals.

If there is none, we create one and pilot test it in the 3-selected hospitals.

WHO

ROJoson's Approach

Floyd L. Helping midwives in Ghana to reduce maternal mortality. African Journal of Midwifery and Women’s Health. 2013 Jan-Mar; 7(1).

http://www.kybeleworldwide.org/uploads/6/8/4/7/6847709/liz_ajm_paper.pdf

https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf

Quality Improvement for Emergency Obstetric Care : EngenderHealth

Quality Improvement for Emergency Obstetric Care : EngenderHealth

https://www.engenderhealth.org/files/pubs/maternal-health/qi-for-emoc-manual.pdf

Quality improvement for Emergency Obstetric Care: it involves a state of readiness that will enable you and the team to respond appropriately to obstetric emergencies in a way that fulfills the needs and rights of your clients.

Readiness: Achieving and maintaining a state of preparedness in the facility to provide quality EmOC. This includes staff available with requisite skills and a willingness to respond to clients 24 hours a day, 7 days a week, available and functional equipment and supplies, and adequate infrastructure.

Response: Providing prompt, appropriate care when emergencies arise, according to acceptable clinical standards and protocols.

Rights: Providing services in a manner corresponding to the rights and needs of all clients.

http://apps.who.int/iris/bitstream/10665/199179/1/WHO_HIS_SDS_2015.26_eng.pdf?ua=1

WHO Safe Childbirth Checklist

- A framework for the evaluation of quality of care in maternity services

http://eprints.soton.ac.uk/40965/1/12757_Matthews.pdf

- Consultation on Improving measurement of the quality of maternal, newborn and child care in health facilities (WHO - 2013)

http://apps.who.int/iris/bitstream/10665/128206/1/9789241507417_eng.pdf

In the “Consultation on Improving measurement of the quality of maternal, newborn and child care in health facilities” published by WHO in 2013 (10), the participants identified core maternal health indicators in the antenatal, intrapartum and postpartum care, including screening, prevention or management of major causes of maternal mortality.

Of all interventions in the antenatal period, the group considered that measurement of blood pressure is the most important for the diagnosis and early management of hypertensive disorders in pregnancy. Magnesium sulfate is the preferred anticonvulsant for the management of severe preeclampsia and eclampsia, while oxytocin is the preferred uterotonic for prevention of postpartum haemorrhage in all births. Hence, the group agreed to include indicators of compliance with these evidence-based practices.

Prolonged obstructed labour is an important cause of maternal and perinatal mortality and morbidity. The group agreed that use of an indicator linked to partography (e.g. number of partographs correctly completed) or caesarean section (e.g. not performed at all levels, lack of consensus on optimal rate) would not be suitable and agreed on use of the proportion of women in active labour (with a cervical dilatation of at least 4 cm on dilatation) for more than 12 h as the indicator. These women should have been delivered in the facility after augmentation of labour or operative delivery or should have been referred elsewhere for these interventions. Ideally, intrapartum stillbirth as an indicator of the quality of intrapartum care should include all fetuses weighing 1000 g or more or after 28 weeks of gestation. The group recognized that decision-making for low birthweight and short gestational age categories depends on the availability of resources: personnel are reluctant to intervene for the sake of the fetus when resources are limited; however, setting a birthweight cut-off of 1500 or 2000 g would negatively affect recording of data on stillbirths. Hence, the indicator proposed is based on the WHO recommended birthweight cut-off for international comparison. Puerperal sepsis is another important cause of maternal death and is often linked to the quality of care during labour and childbirth. As women who give birth in facilities are often discharged home before clinical signs of severe sepsis appear, the group agreed to include readmissions for sepsis in the indicator.

The groups agreed to include four general indicators. Stock-outs of drugs in health facilities affect the quality of care. For mothers and newborns, the group agreed to include oxytocin, magnesium sulfate, dexamethasone, oral amoxicillin and injectable gentamicin as tracer medicines. These medicines are among the 13 United Nations lifesaving commodities. Rapid diagnostic tests for malaria and antimalarial and antiretroviral medicines were considered context-specific tracer medicines. Death reviews are an important part of quality assessment and improvement. The group agreed on an indicator of the proportions of maternal, perinatal and child deaths that were reviewed in each facility. The availability of soap and running water or an alcohol-based hand rub to prevent infection and the availability of a safe, uninterrupted oxygen supply in labour and childbirth, neonatal and paediatric wards are also core general indicators.

Criteria for assessing indicators

Ú Action-focused: It is clear what should be done to improve outcomes associated with this indicator (e.g. vaccination to reduce neonatal tetanus).

Ú Important: The indicator and the data generated will make a relevant, significant contribution to determining how to respond to the problem effectively.

Ú Operational: The indicator is quantifiable; the definitions are precise, and reference standards are available and tested or could be developed.

Ú Feasible: It will be feasible to collect the data required for the indicator in the relevant setting.

Ú Simple and valued: The people involved in the service can understand and value the indicator.

Source: Adapted from Harmonized reproductive health registries. Oslo: Norwegian Institute of Public Health, 2013.

In 2013, WHO conducted a comprehensive review of studies on quality improvement globally to identify facilitators and barriers to good quality of care for maternal, newborn and child health. There are several definitions and models of quality of care. For the purpose of the review, evidence was collected on the three levels of health systems suggested by Donabedian:1 structure (setting, material and human resources and organizational structures, standards and regulations), process (giving and receiving care) and outcomes (improvements in health outcomes, health behaviour, patients’ knowledge and patients’ satisfaction). The data from the review of published and unpublished systematic reviews were analysed within the WHO organizational management framework for health systems. Priorities, facilitators and barriers to improving the quality of care were identified and grouped into eight interrelated domains: the six domains of the WHO framework (information, patient and population engagement, leadership, organizational capacity, regulations and standards and models of care) and two other domains (communication and satisfaction) (Figure 1).

http://www.jsieurope.org/safem/collect/safem/pdf/s2943e/s2943e.pdf

There exists no blueprint for the evaluation of safe motherhood programmes and the choice of indicators and evaluation design depends on who the decision-maker is, and on what types of decisions will be taken as a consequence of the findings.

Maternal mortality is not anymore recommended as a measure against which to assess the success of safe motherhood programmes, and little is known about the value of morbidity as an alternative indicator.

In contrast, adequate tools exist to assess the provision, coverage and utilisation of safe motherhood services.

Because none of the indicators are perfect and none are able by themselves to point to the actions required for improving access to and use of obstetric care, the assessment of safe motherhood services must rely on a variety of indicators.

For the evaluation of the quality of obstetric care, it may be preferable to focus on small-scale facility based efforts that incorporate mechanisms for improvements rather than attempt to measure complex processes or outcomes across facilities or providers.

Multiple Indicators of Use of and Need for Obstetric Care Many authors promote the use of a single indicator of use of and need for obstetric care and few studies have assessed how the various indicators compare in their capacity to capture the use and need for obstetric care. In Indonesia, because we were uncertain as to the reliability and precision of any single indicator, we preferred to base our evaluation on a number of indicators. Figure 4 shows a comparison between districts at baseline in the proportion of complications admitted to EOC facilities, caesarean section rates, MOI for AMI rates, and OVER for breech and twin deliveries (figure 4). The consistency of the pattern across various indicators is striking. All the indicators suggested that there was substantial inequality between districts in the degree to which the need for obstetric care was met, with one of the districts (Barito Kuala) showing a constant deficit compared to the other districts. The consistency of the pattern regardless of indicators strengthened our conclusions when the findings were presented to the health authorities, as weaknesses in one indicator could not be used to explain away the real differences. Since all these indicators rely on data from the same hospital registers, and since the marginal cost of obtaining the data on all rather than one indicator was small, we recommended the use of a number of indicators for continued monitoring of the safe motherhood programme in Indonesia.

The design of an evaluation will largely depend on the kind of inference decision makers wish to make as well as how confident they need to be that any observed effects are in fact due to the project or programme (Habicht et al. 1999). For large-scale programmes, the most relevant question is whether the expected changes have occurred. Demonstrating change will largely depend on how easily and accurately the desirable indicators can be measured. Inferences depend on the comparison with previously established criteria, between geographical areas or over time. For example, to determine the trends in met need for specialised obstetric care in the three districts in Indonesia, we compared the observed proportion of admissions for MOI for AMI with the reference standard of 1%, between the districts and over time (figures 3 and 4). This evaluation not only revealed that one of the districts (Barito Kuala) fell far short of the 1% reference and of the rates in the two other districts at baseline but also that there was a worrying decline in the trend in met need for obstetric care over time. Presentation of the findings to the local and national health authorities generated enormous interest and debate. Although the above assessment merely describes whether or not the expected changes have occurred, one may often reasonably ascribe an observed success (or the lack thereof) to the programme being evaluated. In Indonesia, for example, the dramatic increases in skilled attendance at birth over time provided the Government with the necessary reassurance to continue its support for the training and posting of midwives in every village. The failure of the programme to lead to an increase in the use of specialised care in hospitals, on the other hand, highlighted areas for further improvement. The midwives had little in terms of referral support (the ambulance resides at the health centre, but the driver may not always be there), cost of transport is high, and the fees for emergency medical care are high. Policy decisions and actions are still required to increase referral and ensure quality services at referral level. Most importantly, concerted efforts and commitment will be needed to contain costs of maternal health services, and to make services affordable for the poor.

One of the main criticisms of the above design is its inability to causally link programme activities to observed changes since there is no external control group to verify whether these changes would not have taken place anyway. More complex evaluation designs, however, not only demand additional time, resources and expertise, the existence of an external control group does not necessarily rule out all alternative explanations for the observed changes (Campbell et al. 1997). Non-randomly selected control groups are likely to be systematically different from the intervention areas, and efforts to exclude outside influences in both control and intervention groups will still be necessary. Only randomised controlled trials can provide ultimate proof of causality, but these are neither feasible nor desirable for the evaluation of large-scale safe motherhood programmes. From a practical point of view, less stringent designs are often sufficient to decide about the future of a safe motherhood programme.

While the evaluation should deliver the answers in time for the decision- makers to incorporate the findings in the design and planning of interventions, sufficient time should be given to allow the programme to have an effect. As a general rule, no less than 3-5 years are required for an intervention to have an effect (Habicht et al. 1999). Experience from the Prevention of Maternal Mortality (PMM) network suggests that even longer time periods may be needed to substantially increase the numbers of women using obstetric services.

http://f1000research.com/articles/5-166/v1

Vlad I, Paily V, Sadanandan R et al. Improving quality for maternal care - a case study from Kerala, India [version 1; referees: 1 approved]. F1000Research 2016, 5:166 (doi: 10.12688/f1000research.7893.1)

Improving quality for maternal care - a case study from Kerala, India [version 1; referees: 1 approved]

Ioana Vlad1, VP Paily2, Rajeev Sadanandan3, Françoise Cluzeau4, M Beena5, Rajasekharan Nair6, Emma Newbatt7, Sujit Ghosh7, K Sandeep8, Kalipso Chalkidou4

Author affiliations

Grant information

Abstract

Background: The implementation of maternal health guidelines remains unsatisfactory, even for simple, well established interventions. In settings where most births occur in health facilities, as is the case in Kerala, India, preventing maternal mortality is linked to quality of care improvements.

Context: Evidence-informed quality standards (QS), including quality statements and measurable structure and process indicators, are one innovative way of tackling the guideline implementation gap. Having adopted a zero tolerance policy to maternal deaths, the Government of Kerala worked in partnership with the Kerala Federation of Obstetricians & Gynaecologists (KFOG) and NICE International to select the clinical topic, develop and initiate implementation of the first clinical QS for reducing maternal mortality in the state.

Description of practice: The NICE QS development framework was adapted to the Kerala context, with local ownership being a key principle. Locally generated evidence identified post-partum haemorrhage as the leading cause of maternal death, and as the key priority for the QS. A multidisciplinary group (including policy-makers, gynaecologists and obstetricians, nurses and administrators) was established. Multi-stakeholder workshops convened by the group ensured that the statements, derived from global and local guidelines, and their corresponding indicators were relevant and acceptable to clinicians and policy-makers in Kerala. Furthermore, it helped identify practical methods for implementing the standards and monitoring outcomes.

Lessons learned: An independent evaluation of the project highlighted the equal importance of a strong evidence-base and an inclusive development process. There is no one-size-fits-all process for QS development; a principle-based approach might be a better guide for countries to adapt global evidence to their local context.

Box 1. Summary points

• • 1. In the development of QS in LMIC contexts, local buy-in for the process of development as well as for the end product bear equal importance.

  • 2. There is no one-size-fits-all process for QS development - instead, a principle-based approach might be a better guide for countries to adapt global evidence to their local context.

  • 3. Agencies like NICE International, which provide technical support for evidence-informed decision-making processes, will maximise their effectiveness if the local demand and the capacity for such processes (and their products) is stimulated and policy makers fully engaged.

Methods

Development of quality standards in Kerala

The formal partnership between the Government of Kerala, represented by the Principal Secretary for Health and Family Welfare, the KFOG and NICE International was launched in 2012. It resulted in ten QS related to management and prevention of post-partum haemorrhage (PPH) (QS 1-5) and hypertension in pregnancy (QS 6-10). The QS were launched in January 2013, in the presence of the UK Health Minister and the Principal for Health in Kerala.

Local ownership was a core principle of the QS development process, with the Government of Kerala and KFOG taking a leadership role. NICE International’s contribution was to (a) provide a technical and methodological framework for the development of the QS; (b) support the institutional partnerships between the Government of Kerala, the KFOG and other local stakeholders.

In terms of technical and methodological support, the NICE framework and processes that underpin development of QS for the UK National Health Service (NHS) were used. This includes the selection of high-priority topics for quality improvement in a defined service area, and combines evidence-based guidance with stakeholder priorities and evidence of current practices through a deliberative process (ran by a QS advisory committee), ultimately resulting in a series of quality statements and corresponding measurable indicators13. For the NHS, as for the Kerala health system, developing QS is a highly contextualised process. As such, the NICE framework was adapted to fit the local context, by identifying institutional decision-making rules, key stakeholders and health system functioning characteristics in Kerala.

Locally generated evidence played a key role, particularly in the identification of the leading causes of maternal death in Kerala and therefore the key priorities for the QS. The process was fundamentally informed by the Confidential Review of Maternal Death (CRMD) Audit, which has been run by the KFOG since 2004 and is the only one of its kind in India11,12. As shown in Figure 1, PPH and hypertension are the two main causes of maternal mortality. Furthermore, they are estimated to consistently account for between 29–44% of maternal deaths in Kerala between 2006–200914.

Together with the findings of the CRMD, local epidemiological data and routinely reported systems data (e.g., the Sample Registration System conducted by the Office of the Register General) were assessed using deliberative multi-stakeholder processes convened with mentorship from NICE International. This mentorship consisted of a total of eight workshops (four during the development period and four during implementation). The multi-stakeholder workshops that comprised the QS development process functioned to support the creation and maintenance of institutional links, most notably between KFOG and the state’s Government. Following an initial workshop in June 2012, focused on the active management of the third stage of labour (one of the ten statements included in the first edition of the finalised standards), a multidisciplinary group was established to lead on the development of the standards, the wider consultation process for each statement, and the implementation of the QS. Members included key policy-makers (the Principal Secretary, the Director of the State's National Health Mission-NHM) and leading gynaecologists and obstetricians, nurses and administrators from across Kerala.

The group developed quality statements derived from evidence-based guidelines published by the KFOG, NICE, the World Health Organization, and the UK Royal College of Obstetricians and Gynaecologists (see Box 2 for an example of a quality statement and its link to global guidelines), but adapted based on the experience of practising obstetricians and nurses in Kerala.

Quality of care is needed in hospitals.

McCarthy J, Maine D. A framework for analyzing determinants of maternal mortality. Stud Fam Plann. 1992;23(1):23–33.

Stud Fam Plann. 1992 Jan-Feb;23(1):23-33.

A framework for analyzing the determinants of maternal mortality.

McCarthy J1, Maine D.

Author information

Abstract

Hundreds of thousands of women in developing countries die each year from complications of pregnancy, attempted abortion, and childbirth. This article presents a comprehensive and integrated framework for analyzing the cultural, social, economic, behavioral, and biological factors that influence maternal mortality. The development of a comprehensive framework was carried out by reviewing the widely accepted frameworks that have been developed for fertility and child survival, and by reviewing the existing literature on maternal mortality, including the results of research studies and accounts of intervention programs. The principal result of this exercise is the framework itself. One of the main conclusions is that all determinants of maternal mortality (and, hence, all efforts to reduce maternal mortality) must operate through a sequence of only three intermediate outcomes. These efforts must either (1) reduce the likelihood that a woman will become pregnant; (2) reduce the likelihood that a pregnant woman will experience a serious complication of pregnancy or childbirth; or (3) improve the outcomes for women with complications. Several types of interventions are most likely to have substantial and immediate effects on maternal mortality, including family planning programs to prevent pregnancies, safe abortion services to reduce the incidence of complications, and improvements in labor and delivery services to increase the survival of women who do experience complications.

http://www.cpc.unc.edu/measure/prh/rh_indicators/specific/sm

Safe Motherhood

Conceptual Model

Several different models or frameworks exist to help program managers and communities understand the determinants of maternal mortality (Campbell et al., 1997; McCarthy and Maine, 1992; Thaddeus and Maine, 1994; Koblinsky et al., 2000). The "Three Delays Model" identifies the points at which delays can occur in the management of obstetric complications at the community and facility level.

The first "delay" (delay in deciding to seek care) may relate to a number of factors, including the lack of knowledge about obstetric danger signs, community perception of poor quality facility care, or the lack of health services availability which increases the opportunity costs and therefore reduces the likelihood of care seeking.

The second "delay" (delay in identifying and reaching a medical facility) relates to the geographical proximity and accessibility of health services, and includes factors such as the availability of transportation.

The third "delay" (delay in receiving appropriate care at health facilities) is related to factors in the health facility, including the availability of staff, equipment, and resources as well as the quality and (in some cases) the cost of services.

Methodological Challenges of Evaluating Safe Motherhood Interventions

In addition to the changes in the definition, policies, and strategies as well as the emergence of new public health problems that drive the need for an increasingly wide range of indicators, monitoring and evaluating safe motherhood programs pose a number of inherent methodological challenges. These include, but are not limited to, the following issues.

• Maternal mortality is difficult to measure, and estimates of maternal mortality should not be used for monitoring purposes.

Maternal mortality estimates are valuable and particularly relevant now due to the need to evaluate MDG-5, improve maternal health. Mortality estimates do, however, have a number of inherent methodological weaknesses that limit their use for monitoring purposes; they are costly, they do not explain the causes of maternal deaths, and they cannot detect short term change (Graham et al., 2008).

Few developing countries have registration systems with sufficiently wide coverage to provide accurate national estimates of maternal mortality. Alternative approaches to deriving estimates, such as surveys and the sisterhood method, also have limitations in that the estimates are relatively imprecise and relate to periods several years before the survey. Even in countries where the maternal mortality is high, maternal deaths are rare events; therefore, surveys are very costly because of the need for large sample sizes to provide a statistically reliable estimate. The wide confidence limits on the estimate also make it very difficult, if not impossible, to assess whether change has occurred over time. For these reasons, maternal mortality estimates, if required, should be measured only infrequently (e.g., once a decade), and program-level indicators that measure the availability, use, and quality of care are recommended for monitoring purposes (AbouZahr, 1999).

• Maternal morbidity is difficult to define, interpret, and measure

Maternal morbidity is much more common than maternal death; thus, the prevalence of maternal morbidity provides a conceptually appealing alternative outcome to measure. Moreover, relatively little is known about the burden of reproductive morbidity; more work is needed to explore the dimensions and determinants of the problem as well as to evaluate the effectiveness of interventions.

The link between morbidity and mortality is not straightforward. Safe motherhood interventions primarily offer secondary prevention; that is, they prevent deaths from complications rather than preventing the complications themselves. Furthermore, unlike death, which has a very defined outcome, measures of morbidity are difficult to define and thus to measure. Even persons with medical training may misclassify complications; consequently, generating any meaningful comparative measures is difficult (Fortney and Smith, 1999).

• • Safe motherhood outcomes need to be measured for two individuals: the mother and baby

Under most circumstances interventions that benefit or harm the mother similarly affect the baby and vice versa. Some exceptions are notable. For example, a cesarean section for fetal distress may be critical to ensure a good neonatal outcome but may more negatively influence the mother's health than a normal vaginal delivery will.

• The provision of appropriate maternity care is a complex process that requires multiple indicators to monitor

Unlike most areas of public health, providing appropriate maternity care is a complex process that involves a wide range of preventive, curative, and emergency services as well as several different levels of care (from the community to the facility and beyond). The occurrence of an emergency sets into motion a complex chain of events to ensure that a woman receives adequate care. First, the family needs to recognize the problem and be able to access the appropriate services. Second, the equipment, supplies and medicines must be available at the facility to enable the care provider to make the correct diagnosis and to provide appropriate treatment promptly. If definitive care cannot be provided at the first level, then transport needs to be available quickly to take the woman to a higher level of care that must also deliver the appropriate services. Problems at any one of these stages may mean that the woman receives substandard care, which may be of critical importance in determining the outcome. From a program perspective, a series of indicators is required to reveal whether a problem occurs on the "demand" or "supply" side of the equation, and hence, whether the interventions need to address community mobilization, behavior change, health system performance, or a combination of these factors.

• • Interpreting whether outcomes are attributable to program interventions is difficult, because most interventions consist of "bundled" services

Demonstrating change as a result of a safe motherhood program is difficult because programs usually provide a package of care to communities rather than providing one single intervention. Therefore, such programs do not lend themselves easily to randomized control trials or cluster randomized community-based trials. Many programs adopt "before-after" designs for evaluation purposes that can demonstrate "plausible association" but that fall short of determining causality (UNFPA et al., 1997).

Indicator Selection

The indicators in this section are intended mainly for use at the national level or in the context of large-scale programs. However, many can serve in a much wider monitoring and evaluation context. These indicators were selected on the basis that they:

• Are widely used by international organizations and/or ministries of health;

• Have a relatively strong link to health or mortality outcomes; and

• Will likely provide valid comparisons at a national and international level.

Safe Motherhood Indicators

http://www.cpc.unc.edu/measure/prh/rh_indicators/indicator-summary

1. Existence of a safe motherhood strategic or operational plan to promote access and/or quality of safe motherhood services

2. Minimum package of antenatal care services defined

3. Maternal neonatal program index (MNPI)

4. Number of facilities per 500,00 providing basic and comprehensive emergency obstetric care

5. Geographic distribution of EmOC facilities

6. Percent of health facilities with skilled attendant (doctor, nurse or midwife) available 24 hours a day, 7 days a week

7. Percent of communities that have an emergency transport plan in place

8. Percent of audience that know three primary warning/danger signs of obstetric complications

9. Percent of skilled health personnel knowledgeable in obstetric warning signs

10. Percent of women attended, at least once during their pregnancy, by skilled health personnel for reasons relating to the pregnancy

11. Percent women attended at least four times for antenatal care during pregnancy

12. Percent of pregnant women whose blood pressure was checked at first ANC visit

13. Percent of pregnant women who had weight checked at first ANC visit

14. Percent of pregnant women attending antenatal clinics screened for syphilis

15. Percent of women who received at least two doses of tetanus-toxoid vaccine in their last pregnancy

16. Percent of pregnant women who receive anthelminthic treatment during pregnancy

17. Percent of deliveries attended by skilled health personnel

18. Percent of births in health facilities

19. Percent of all births in EmOC facilities

20. Percent of women who received prophylactic oxytocin for vaginal delivery before delivery of placenta

21. Percent of mothers examined every 30 minutes during the first two hours after delivery

22. Percent of women discharged from facilities in less than 24 hours after childbirth

23. Percent of women receiving postpartum care by a skilled health personnel within two days of childbirth

24. Percent women receiving postpartum/postabortion family planning counseling (as a percent of women seen)

25. Percent of maternal deaths due to indirect causes at EmOC facilities

26. Percent of facilities that conduct case review/audits into maternal death/near miss

27. Percent of pregnant women with obstetrical complications treated within two hours at a health facility

28. Cesarean sections as a percent of all births

29. Case fatality rate (CFR) - all complications

30. Direct obstetric case fatality rate

31. Maternal mortality ratio (MMR)

32. Met need for EmOC

Campbell et al., 1997; McCarthy and Maine, 1992; Thaddeus and Maine, 1994; Koblinsky et al., 2000).

Delivery in Model 4 facilities in developing countries does not necessarily guarantee low mortality Koblinsky et al., 1999

TABLE 5-1Models of Health Care During Labor and Delivery

SOURCE: Adapted from Koblinsky et al., 1999.

Improving Birth Outcomes: Meeting the Challenge in the Developing World.

http://www.ncbi.nlm.nih.gov/books/NBK222101/

Countries meet their specific needs by tailoring that overall process.

THE EVIDENCE BASE

Evidence concerning the effectiveness of specific interventions to prevent adverse birth outcomes

The clinical and cost-effectiveness of interventions within a health care system would ideally be determined through randomized, controlled trials (RCTs), since they provide the most reliable evidence. However, RCTs have not been used extensively in evaluating community interventions (Smith et al., 2000) because of the cost and complexity of very large trials or because denial of services to a control group when they are widely believed to be beneficial may be considered unethical. Because maternal mortality is a relatively rare event, very large populations need to be studied. Such trials are also complex owing to their multiple components and the involvement of several levels of government (Sorensen et al., 1998)

Clearly the evidence base for improving birth outcomes within the health care systems of diverse countries would be strengthened by conducting RCTs of interventions in the systems in question. It is important for future research to meet the challenges imposed by cost and complexity so that policies and programs can be based on a stronger scientific footing. For now, given the current lack of RCTs to evaluate the effectiveness of health care systems, and the urgent need to improve birth outcomes, the committee has examined less rigorous attempts to integrate interventions into health care systems and programs.

This chapter therefore focuses on the feasibility of implementing systems and programs of maternal and infant care in different settings, the problems encountered, and the lessons learned. When published evidence on the overall effectiveness of these systems and programs is available, it has been reviewed. Since this evidence often consists of comparisons before and after interventions in the same geographic setting, participants versus nonparticipants in the same setting, or settings that have implemented a program versus those that have not, caution is advised in drawing inferences about the causal effects of the systems or programs of care.

Which model is appropriate?

Determining the best model of labor and delivery care for a particular country or region, and the most effective and efficient steps to reach it, require future research (Graham et al., 2001). Each model, even Model 4, can be recommended only after establishing its clinical- and cost-effectiveness, feasibility, and family/patient acceptance in specific settings. Furthermore, countries must have the resources to successfully implement the changes needed. Variations on Models 2 and 3 care, as described above, are likely to be the most cost-effective facilities for uncomplicated deliveries in low resource settings. Basic and comprehensive EOC are clearly needed for complicated deliveries.

Recognition of pregnancy complications and their management is central to reducing maternal, fetal, and neonatal deaths, yet success in doing so when most women deliver at home not attended by a professional attendant remains a challenge. Scarce health resources should therefore be managed with the primary goal of achieving skilled delivery at all births (i.e., Model 2 or 3). This can be accomplished by creating partnerships between midwives, with their medical skills, (and village health workers [VHWs] or) TBAs, with their knowledge of and access to individual patients, the community, and local birthing traditions. Where resources permit, identification of a specific target, such as the underserved, for improved quality of care and efficiency of referral can facilitate the transition from Model 2 to Model 3 care. Key needs can be identified and met using population-based surveys (Pathmanathan and Dhairiam, 1990), standard risk analysis (Yan et al., 1989), or death audits (Wilkinson, 1997).

In well-functioning health care systems, normal births are supported but not overmedicalized, limiting costs and reducing the risk of iatrogenic complications, while complicated births receive prompt, appropriate treatment (Jahn and De Brouwere, 2001). In Jamaica and Sri Lanka, developing countries in which physicians attend about 15 percent of deliveries—the approximate percentage of all births that involve potentially life-threatening complications (World Health Organization, 1994)—maternal mortality has been considerably reduced (Graham et al., 2001). In Chile, midwives and physicians typically work together to provide a high level of institution-based maternal and neonatal care (Segovia, 1998). Midwives attend 70 percent of all deliveries in that country; physicians handle the remainder. These take place in Model 3 or 4 facilities which also provide the vast majority of antenatal care. However, any country can develop a mix of models to suit local needs such as urban or rural. In places where women equate safe delivery with delivery in a facility, they may prefer a hospital that provides comprehensive care or a birthing facility affiliated with a referral hospital. Because of the higher cost of Model 4 deliveries, policy makers can decide where to provide quality Model 3 care for normal deliveries with links to referral services for pregnancies with complications that require Model 4 care (Koblinsky et al., 1999).

Self-referral for delivery care far outstrips emergency referrals in many hospitals in developing countries (Murray et al., 2001; Jahn and De Brouwere, 2001). Frequent self-referral for delivery without specific medical reason indicates that many women bypass community-level services, while the small percentage of emergency referrals indicates that many complicated births do not receive adequate care (Jahn and De Brouwere, 2001). Where resources are limited, maximum cost-effectiveness will be obtained when the majority of deliveries performed at higher-level facilities are complicated births. This requires strengthening the referral system, as described in the next section.

BUILDING CAPACITY FOR REPRODUCTIVE HEALTH CARE

Access to quality reproductive health services is key to improving birth outcomes (Pittrof et al., 2002). In developing countries, this involves building health care capacity in the form of facilities, equipment, supplies, and— most important—personnel. An acute shortage of physicians, midwives, and nurses throughout much of the developing world is exacerbated by their unequal distribution. The vast majority of these professionals and nearly all obstetricians, pediatricians, and other specialists practice in urban areas (Kowalewski and Jahn, 2001). Midwives are more likely to work in rural settings, but their numbers are too small to fill the gap in care; according to a 1990 estimate, developing countries average about one midwife per 30,000-300,000 people (Kwast, 1991). Thus this section first describes several approaches to increasing the numbers of skilled assistants in public health services, the quality of care they provide, and their association with improved birth outcomes. These efforts can be further advanced through collaboration with private care providers, NGOs and other not-for-profit organizations, and professional organizations of health care providers.

An obvious barrier to achieving greater coverage for the most effective health interventions, including those that would reduce maternal and neonatal mortality, is the low level of total health expenditure in developing countries. With the average annual per capita health care expenditure in low-income countries at US$26 in 2002—and only half that amount in the 48 poorest countries—additional funds are clearly necessary to improve birth outcomes and health care worldwide (Jha et al., 2002). The third part of this section, on the financing of reproductive health services in developing countries, identifies potential sources of funding to begin to address this shortfall. The final part of this section discusses health system decentralization and sector-wide approaches to reproductive health. These reforms have been adopted by several countries in an effort to improve access to good quality health care.

Staff Development and Training

Several factors contribute to the lack of general physicians and specialists in most developing countries, including limited resources for health care, the inadequate capacity of medical schools, and the loss of physicians to opportunities abroad. The emigration of physicians can be stemmed by creating a more attractive career path with faster advancements, publicly acknowledging medical and other accomplishments, and providing more competitive salaries. Where the distribution of physicians is the major problem, strong national leadership is needed to establish rural coverage as a priority and provide incentives to physicians to work in rural areas before settling in cities. For example, physicians who agree to serve in rural areas might be forgiven the cost of their training; however, such agreements must be rigorously enforced to be effective (Kowalewski and Jahn, 2001). The need for specialized care in some underserved areas has been filled by general practitioners who have acquired the skills needed for operations such as cesarean delivery.

In order to increase the effectiveness of physicians, nurses and other health assistants can assume certain additional tasks under the supervision of a physician. In countries where it is permitted, nonphysician medical assistants have received further training to enable them to perform emergency surgery and administer anesthesia. In Burkina Faso, Malawi, Mozambique, Tanzania, and Zaire, nonphysician staff are trained to perform surgery and obstetric care in district hospitals or health centers where physicians are not available (Kowalewski and Jahn, 2001; Rosenfield, 1992; Adeloye, 1993; da Luz Vaz and Bergström, 1992; Pereira et al., 1996; Duale, 1992). In addition to increasing the coverage for emergency services, competent nonphysicians incur lower salary and training costs than do doctors, and some evidence suggests that they communicate more effectively with patients (World Bank, 1993). Follow-up costs must also be considered, however, as nonphysicians who provide specialized services may require a high level of supervision (Hopkins et al., 1996; Loutfi et al., 1995).

Skilled birth attendants—whether midwives, physicians, or nurses— require ongoing training. Programs of instruction for skilled caregivers can be built on evidence-based, nationally approved standards, such as the skill base outlined inAppendix C, Essential Skills Required for Birth Attendants. While midwives need instruction in clean and safe delivery, field reports from Guatemala and Bolivia indicate that many physicians and nurses have not been sufficiently trained in partograph use, breech delivery, newborn resuscitation, and the control of postpartum hemorrhage (Koblinsky et al., 2000). A sound knowledge of procedures for a clean and safe delivery serves as a foundation for training in the treatment of complications. Expertise is gained through hands-on experience and maintained through caseload requirements, on-going training, and evaluation (McDermott et al., 2001; see Appendix C). The performance of skilled birth attendants should be monitored for the purpose of improving health care systems, as well as to ensure individual accountability (Gunathunga and Fernando, 2000).

Regular emergency drills or simulations can help health workers maintain a state of readiness to deal with emergencies. Courses in life-saving skills for midwives have been successful in addressing these needs, and could also be offered to nurses, clinical assistants, and general physicians. Several studies indicate that nonspecialists can be taught to perform life-saving obstetric techniques effectively (da Luz Vaz and Bergstrom, 1992).

Providing universal care during childbirth by training TBAs has not been shown to be effective. After receiving training in clean delivery practices and the recognition of complications, TBAs in the Gambia were initially found to have had a positive effect on maternal health, yet three years later, the maternal mortality ratio remained near 700 per 100,000 births (Greenwood et al., 1990). Training of TBAs—once thought to be an affordable way to reduce mortality during childbirth—is no longer considered an effective investment of limited funding resources.

Patterns of care for women during pregnancy and childbirth in most developing countries, particularly in rural communities, are strongly influenced by cultural and traditional factors. In settings where TBAs are responsible for childbirth, few women receive antenatal care (Nylander and Adekunle, 1990). When obstetric problems arise, sociocultural factors (such as women's social status and the use of traditional healing practices) frequently pose barriers to their seeking medical treatment (The Prevention of Maternal Mortality Network, 1992; Okolocha et al., 1998).

Financing

MANAGING HEALTH CARE SYSTEMS

To improve birth outcomes in developing countries, health care leaders must identify the interventions, programs, and strategies likely to have the greatest impact on maternal, fetal, and neonatal mortality. They must then allocate the resources needed to achieve a successful result. An effective process for making such decisions involves the following steps: defining and prioritizing health problems, assessing the performance of current health services, selecting the best intervention, implementing it, and assessing its impact (Lawn et al., 2001). Health care leaders and providers and the community they serve must all participate in this process if it is to be successful.

The definition of key health problems is itself a process, which begins with the collection and analysis of data on health outcomes (in this case, adverse birth outcomes such as maternal, neonatal, or fetal mortality) in the community and comparison with standard populations. Key health problems revealed in this way are further defined in terms of the gaps in services they represent. Both criteria—the magnitude of the problem and the local availability of solutions—are weighed in the setting of priorities among health problems.

To assess the performance of current health services in addressing a priority problem (as defined by an adverse birth outcome), it must be determined whether the most effective services are provided, whether services reach the vast majority of the population, and whether the services are of good quality. Community input, in addition to that of health leaders and health care providers, is critical to obtaining an accurate assessment, and one that reveals opportunities for interventions to reduce adverse birth outcomes.

Selecting the best intervention to address a problem requires a strong evidence base that confirms the importance of the chosen problem in the local population. The promise of each potential intervention is assessed by examining evidence for its clinical-effectiveness, cost-effectiveness, feasibility and sustainability, and acceptability to the local community. In addition to the new interventions being considered, current interventions and the effect of no intervention should be assessed. Involving local leaders early in the assessment process helps ensure that a needed, wanted, and successful intervention is implemented.

The successful implementation of a chosen intervention requires a clear vision of the desired outcome and recognizes the need for community involvement and investment in the project. Plans for implementation must answer many specific questions. How will the intervention be introduced? Who will provide the services, and at what cost? How will the community be involved in making the intervention successful? These and other needs should be anticipated in the planning process. After implementation, health care providers must consider two questions. First, is the chosen intervention the best way to address the problem? Second, is the intervention being effectively carried out? That is, are the services of good quality and are they reaching most of the population? The answers to these questions can be determined through the surveillance of birth outcomes and evaluation of their change as a result of the intervention.

Experience in industrialized countries suggests that interventions must be tailored to local conditions and that continual monitoring and response is key to maximizing cost-effectiveness (Sorensen et al., 1998). Such fine-tuning of interventions and health care programs is achieved by repeating the steps in the decision-making process to solve increasingly well-defined problems. Surveillance of maternal, fetal, and neonatal mortality (and in some cases, proxy indicators for these outcomes) provides the foundation for identifying, prioritizing, and evaluating interventions to improve birth outcomes. Evaluation of services provides the basis for determining cost-effectiveness and establishes benchmarks for continuing improvement.

Evaluation

Evaluating the impact of an intervention or health care program may involve measurements of key outcomes such as maternal, neonatal, or fetal mortality, or may be based on process indicators such as the proportion of births attended by a skilled caregiver or taking place in a health care facility. Comparisons based on mortality allow policy makers to track the impact of these services using relatively simple and affordable information systems (Graham, 2002). However, such measures depend on accurate determinations of maternal, fetal, and neonatal mortality, which are not available in most developing country settings. In these cases, process indicators can be used to estimate the large-scale impact of maternal and neonatal services (Ronsmans, 2001). Such process indicators must be shown to be strongly associated with key birth outcomes (Gelband et al., 2001), but causal relationships between process and mortality measures have yet to be established.

Cost of services

Ideally, the budgeting and planning of reproductive health services— and indeed, of health care in general—in a particular setting would reflect the most cost-effective means of meeting significant population needs. However, despite wide recognition of the need for quality, cost-effective maternal and neonatal health care, little comparable “cost per outcome” information exists to aid in identifying priority services. Studies to date have tended to address either the cost or the outcome of interventions (or packages of interventions) to reduce maternal or neonatal mortality in specific countries or regions, but rarely provide information on both cost and outcome (Borghi, 2001). In the absence of detailed data on the cost of implementing effective services, policy makers can use costing instruments to assemble key information on reproductive health care needs and service costs for specific populations. Two such instruments, the Mother-Baby Packaging Costing Spreadsheet and the Cost Estimate Strategy, are described in Box 5-4.

Too far to walk: maternal mortality in context.

Author information

Abstract

Risk factors for maternal mortality in a Tertiary Hospital in Kenya: a case control study

Faith YegoEmail author,Catherine D’Este,Julie Byles,Jennifer Stewart Williams andPaul Nyongesa

DOI: 10.1186/1471-2393-14-38© Yego et al.; licensee BioMed Central Ltd. 2014

Received: 22 April 2013Accepted: 16 January 2014Published: 22 January 2014

Open Peer Review reports

Abstract

Background

Maternal mortality is high in Africa, especially in Kenya where there is evidence of insufficient progress towards Millennium Development Goal (MDG) Five, which is to reduce the global maternal mortality rate by three quarters and provide universal access to reproductive health by 2015. This study aims to identify risk factors associated with maternal mortality in a tertiary level hospital in Kenya.

Methods

A manual review of records for 150 maternal deaths (cases) and 300 controls was undertaken using a standard audit form. The sample included pregnant women aged 15-49 years admitted to the Obstetric and Gynaecological wards at the Moi Teaching and Referral Hospital (MTRH) in Kenya from January 2004 and March 2011. Logistic regression analysis was used to assess risk factors for maternal mortality.

Results

Factors significantly associated with maternal mortality included: having no education relative to secondary education (OR 3.3, 95% CI 1.1-10.4, p = 0.0284), history of underlying medical conditions (OR 3.9, 95% CI 1.7-9.2, p = 0.0016), doctor attendance at birth (OR 4.6, 95% CI 2.1-10.1, p = 0.0001), having no antenatal visits (OR 4.1, 95% CI 1.6-10.4, p = 0.0007), being admitted with eclampsia (OR 10.9, 95% CI 3.7-31.9, p < 0.0001), being admitted with comorbidities (OR 9.0, 95% CI 4.2-19.3, p < 0.0001), having an elevated pulse on admission (OR 10.7, 95% CI 2.7-43.4, p = 0.0002), and being referred to MTRH (OR 2.1, 95% CI 1.0-4.3, p = 0.0459).

Conclusions

Antenatal care and maternal education are important risk factors for maternal mortality, even after adjusting for comorbidities and complications. Antenatal visits can provide opportunities for detecting risk factors for eclampsia, and other underlying illnesses but the visits need to be frequent and timely. Education enables access to information and helps empower women and their spouses to make appropriate decisions during pregnancy.

www.everywomaneverychild.org/images/EPMM_final_report_2015.pdf

Strategies toward ending preventable maternal mortality (EPMM)

World Health Organization 2015

Box 2: Ultimate goal of EPMM Guiding principles for EPMM • Empower women, girls and communities. • Protect and support the mother–baby dyad. • Ensure country ownership, leadership and supportive legal, regulatory and financial frameworks. • Apply a human rights framework to ensure that high-quality reproductive, maternal and newborn health care is available, accessible and acceptable to all who need it.

Cross-cutting actions for EPMM • Improve metrics, measurement systems and data quality to ensure that all maternal and newborn deaths are counted. • Allocate adequate resources and effective health care financing.

Five strategic objectives for EPMM • Address inequities in access to and quality of sexual, reproductive, maternal and newborn health care. • Ensure universal health coverage for comprehensive sexual, reproductive, maternal and newborn health care. • Address all causes of maternal mortality, reproductive and maternal morbidities, and related disabilities. • Strengthen health systems to respond to the needs and priorities of women and girls. • Ensure accountability to improve quality of care and equity.