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.
In February 2018, the first Confidential Enquiry into Maternal Deaths (CEMD) Review in Kenya was launched. CMNH supported the Ministry of Health, Kenya to carry out this enquiry and to set up a National Maternal and Perinatal Death Surveillance and Response (MPDSR) Committee and establish a National MPDSR secretariat. Massive haemorrhage was identified as the main cause of death for most women. Hypertensive disorders were also a significant contributor, as were pre-existing conditions such as HIV and anaemia. Recommendations for priority actions following this report have been agreed and will be used to develop policies to improve the quality of care for women.
Dr Mohammed Sheikh, Head, Family Planning Department, Ministry of Health, Kenya: “We received very welcome support from CMNH to conduct the CEMD. We now look forward to working together further to ensure that this doesn’t end with a report – we must go beyond this and put into action the recommendations that the report generated
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.
In December 2018, CMNH coordinated and hosted a WHO capacity-building workshop in Liverpool on the implementation of perinatal death audit. This was targeted at healthcare providers from Europe and Central Asia and built on our earlier work in Turkmenistan and Uzbekistan.
CMNH has also developed national guidelines for perinatal death surveillance and response for Malawi and in 2019, is supporting the implementation of perinatal death audit in Kenya.
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. The process of standards-based audit follows five steps, known as the 'audit cycle':
- Identify a standard(s) for audit
- Assess current practice and compare against agreed standard(s)
- 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
- Actions are implemented
- Practice is re-evaluated subsequently (e.g. 3-4 months interval).
CMNH has developed and published new manuals for improving the quality of ANC and PNC. The manuals outline the essential steps needed to conduct standards-based audit and set out internationally agreed standards including for women- and baby-friendly care, organisation of ANC, management of obstetric complications, PNC for both mother and baby and management and/or prevention of malaria, TB, HIV and other infections. Each standard has a clearly stated and measurable objective as well as criteria for what resources will be required to achieve the standards (structure), what actions will be needed (process) and the expected results (outcomes).
In Malawi, a step-wedge designed trial is ongoing to assess the effectiveness of standards-based audit in 44 healthcare facilities.