Quality of Care – a renewed focus

Mother holding her baby outside their house in Kenya

Quality of care is defined as the extent to which health services provided to individuals and populations improve desired health outcomes. In order to achieve this, healthcare needs to be safe, effective, timely, efficient, equitable, and people-centred (UN, 2015)

Although progress has been made with regard to increasing the coverage of maternal and newborn health interventions over the past two decades, there is increasing recognition that further improvement in maternal and newborn health outcomes will depend on the ability to address the gap between coverage and quality. Improving the quality of facility-based healthcare services and making quality an integral component of scaling-up of interventions that are known to be effective is crucial if health outcomes for mothers and babies are to improve. This will require a renewed global focus.

There are a variety of methods to improve quality of care which are already accepted and used in maternal and newborn health. These include: conducting maternal mortality and perinatal death audit or review, ‘near-miss’ audit and standards-based audit. All three types of audit essentially ask the questions: what was done well, what was not done well, and, how can care be improved in future? In most countries in sub-Saharan Africa and South Asia, the concept of maternal death audit has been introduced and is accepted. Where it is implemented, it helps identify which areas of clinical care or the health systems require improvement.

Maternal Death Surveillance and Response
In most countries the maternal mortality ratio is an estimate based on modelling. There is no contemporaneous information on how many women died, where they died and why they died. Therefore, any strategy to prevent maternal deaths needs to establish a system that identifies all maternal deaths in real time, reviewing these to help healthcare providers, programme managers, administrators and policy-makers understand the cause of and factors contributing to maternal deaths, so that this will guide actions to prevent future deaths. Maternal Death Surveillance and Response is an action-oriented model which promotes the routine identification and timely notification of all maternal deaths, review of maternal deaths to establish cause of and factors contributing to death and, implementation and monitoring of steps to prevent similar deaths in the future. Maternal Death Surveillance and Response is a form of continuous surveillance linking the health information system and quality improvement processes from local to national levels.

Perinatal Death Surveillance and Response
Perinatal deaths include stillbirths and deaths in the first week of life (early neonatal deaths). Half of the world’s babies do not currently receive a birth certificate; and most neonatal deaths and almost all stillbirths have no death certificate, let alone information on the cause of and factors contributing to these deaths. Therefore, it is important that the civil registration and vital statistics (CRVS) systems for counting all births and deaths and assigning cause of death need to be strengthened in all countries, particularly in those countries where the estimated burden is the highest. Perinatal death audit is conducted to examine the cause of and factors contributing to stillbirths and neonatal deaths and to critical analysis of the quality of care received. The purpose is to formulate recommendations and take action to improve the quality of care for mothers and newborns and prevent avoidable deaths in future.

Standards-based audit
Standards-based audit is the systematic review of the quality of care compared to standards of care agreed by all the relevant health managers and providers. Standards are based on evidence-based guidelines for care. Standards-based audit is an evidence-based quality improvement process resulting in better outcomes. The process of standards-based audit follows five steps:

  1. Identify a standard(s) for audit
  2. Assess current practice and compare against agreed standard(s)
  3. Where standard (s) are not met, a root cause analysis (why, why) is conducted to understand the reasons for this and used to identify which changes (remedial actions) are needed
  4. Actions are implemented
  5. Practice is re-evaluated subsequently (e.g. 3-4 months interval).

This is also known as the ‘audit cycle’. Several standards can be audited at the same time and cycles repeated over time as needed to encourage an ongoing process of quality improvement.