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Ogola M, Wainaina J, Muinga N, Kimani W, Muriithi M, Aluvaala J, English M, Irimu G. Development of a small and sick newborn clinical audit tool and its implementation guide using a human-centred design approach newborn clinical audit process and design. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001577. [PMID: 36963070 PMCID: PMC10021839 DOI: 10.1371/journal.pgph.0001577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023]
Abstract
Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the clinical audit process must use a structured tool that comprehensively covers the continuum of newborn care from immediately after birth to the period of newborn unit care. The objective of the study was to co-design a newborn clinical audit tool that considered the key principles of a Human Centred Design approach. A three-step Human Centred Design approach was used that began by (1) understanding the context, the users and the available audit tools through literature, focus group discussions and a consensus meeting that was used to develop a prototype audit tool and its implementation guide, (2) the prototype audit tool was taken through several cycles of reviewing with users on real cases in a high volume newborn unit and refining it based on their feedback, and (3) the final prototype tool and the implementation guide were then tested in two high volume newborn units to determine their usability. Several cycles of evaluation and redesigning of the prototype audit tool revealed that the users preferred a comprehensive tool that catered to human factors such as reduced free text for ease of filling, length of the tool, and aesthetics. Identified facilitators and barriers influencing the newborn clinical audit in Kenyan public hospitals informed the design of an implementation guide that builds on the strengths and overcomes the barriers. We adopted a Human Centred Design approach to developing a newborn clinical audit tool and an implementation guide that we believe are comprehensive and consider the characteristics of the context of use and the user requirements.
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Affiliation(s)
- Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Pumwani Maternity Hospital, Nairobi, Kenya
| | - John Wainaina
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Naomi Muinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Ogola M, Njuguna EM, Aluvaala J, English M, Irimu G. Audit identified modifiable factors in Hospital Care of Newborns in low-middle income countries: a scoping review. BMC Pediatr 2022; 22:99. [PMID: 35180843 PMCID: PMC8855576 DOI: 10.1186/s12887-021-02965-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/19/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Audit of facility-based care provided to small and sick newborns is a quality improvement initiative that helps to identify the modifiable gaps in newborn care (BMC Pregnancy Childbirth 14: 280, 2014). The aim of this work was to identify literature on modifiable factors in the care of newborns in the newborn units in health facilities in low-middle-income countries (LMICs). We also set out to design a measure of the quality of the perinatal and newborn audit process. METHODS The scoping review was conducted using the methodology outlined by Arksey and O'Malley and refined by Levac et al, (Implement Sci 5:1-9, 2010). We reported our results using the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We identified seven factors to ensure a successful audit process based on World Health Organisation (WHO) recommendations which we subsequently used to develop a quality of audit process score. DATA SOURCES We conducted a structured search using PubMed, CINAHL, EMBASE, LILACS, POPLINE and African Index Medicus. STUDY SELECTION Studies published in English between 1965 and December 2019 focusing on the identification of modifiable factors through clinical or mortality audits in newborn care in health facilities from LMICs. DATA EXTRACTION We extracted data on the study characteristics, modifiable factors and quality of audit process indicators. RESULTS A total of six articles met the inclusion criteria. Of these, four were mortality audit studies and two were clinical audit studies that we used to assess the quality of the audit process. None of the studies were well conducted, two were moderately well conducted, and four were poorly conducted. The modifiable factors were divided into three time periods along the continuum of newborn care. The period of newborn unit care had the highest number of modifiable factors, and in each period, the health worker related modifiable factors were the most dominant. CONCLUSION Based on the significant number of modifiable factors in the newborn unit, a neonatal audit tool is essential to act as a structured guide for auditing newborn unit care in LMICs. The quality of audit process guide is a useful method of ensuring high quality audits in health facilities.
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Affiliation(s)
- Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya.
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
- Pumwani Maternity Hospital, Nairobi, Kenya.
| | | | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, 197 Lenana Place, Lenana Road, P. O. Box 43640, Nairobi, 00100, Kenya
- Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Kinney MV, Walugembe DR, Wanduru P, Waiswa P, George A. Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors. Health Policy Plan 2021; 36:955-973. [PMID: 33712840 PMCID: PMC8227470 DOI: 10.1093/heapol/czab011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.
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Affiliation(s)
- Mary V Kinney
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - David Roger Walugembe
- School of Health Studies and Faculty of Information and Media Studies, The University of Western Ontario, London, ON, Canada
| | - Phillip Wanduru
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Peter Waiswa
- Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Asha George
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Sk MIK, Paswan B, Anand A, Chowdhury P, Naskar TK. Deaths during pregnancy, childbirth and puerperium: Exploring causes, context and evidence from Eastern India. J Obstet Gynaecol Res 2020; 46:2366-2374. [PMID: 32924235 DOI: 10.1111/jog.14466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 08/09/2020] [Accepted: 08/20/2020] [Indexed: 11/28/2022]
Abstract
AIM The study was aimed to identify the specific reasons and circumstances of maternal deaths in West Bengal. METHODS The present study is a retrospective study of 317 maternal deaths, conducted between November 2013 and October 2015 at two major referral hospitals of eastern India, West Bengal. The frequencies, proportions, measures of central tendency and dispersion were used to describe the data. The data were analyzed using the statistical software spss version 20.0. ArcGIS 10.1 was also employed to show the distributional pattern of maternal deaths. RESULTS The overall maternal mortality ratio was estimated as 561 per 100 000 live births. Eclampsia or hypertensive disorders of pregnancy contributed to one-third (33.1%, n = 105/317) of maternal deaths. The maternal deaths were more common (41%) among women belonging to the age group of 20-24 years and primiparous (36.9%) group. The average distance for traveling to reach the final hospital was 47.37 km. Approximately, three-fourths (72.2%) of maternal deaths were in the post-partum period. Half of the women (50.5%) sought medical care after 12 hrs of developing complications. The majority of the cases (80.1%) were referred and about 45% of patients had a cesarean section. CONCLUSION The result suggests there was a shift in causes of maternal deaths from hemorrhage to eclampsia. Establishment of separate eclampsia units at lower-level health facilities may be a more plausible pathway to prevent eclampsia-related maternal deaths in West Bengal.
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Affiliation(s)
- Md Illias Kanchan Sk
- Department of Population Policies and Programmes, International Institute for Population Sciences, Mumbai, India
| | - Balram Paswan
- Department of Population Policies and Programmes, International Institute for Population Sciences, Mumbai, India
| | - Ankit Anand
- Population Research Centre, Institute for Social and Economic Change, Bangalore, India
| | - Poulomi Chowdhury
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Tapan Kumar Naskar
- Department of Gynaecology and Obstetrics, Medical College and Hospital, Kolkata, India
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Ugwu GO, Iyoke CA, Ezugwu EC, Ajah LO, Onah HE, Ozumba BC. A Comparison of the Characteristics of Maternal Near-Misses and Maternal Deaths in Enugu, Southeast Nigeria: A 3-Year Prospective Study. Int J Womens Health 2020; 12:207-211. [PMID: 32273776 PMCID: PMC7105884 DOI: 10.2147/ijwh.s237221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/20/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Maternal near-misses, also known as severe acute maternal morbidity, have become globally recognized as an appropriate indicator of obstetric care. Women experiencing maternal near-misses are more in number than maternal deaths, and can provide more specific and detailed evidence, as the patient herself can be a leading source of useful information. OBJECTIVE To determine the frequency of maternal near-misses and maternal deaths in the University of Nigeria Teaching Hospital in Ituku-Ozalla, Enugu, document the primary determinant factor that caused these, and compare cases of maternal near-miss and maternal deaths. METHODS This was a 3-year prospective study of all women admitted for delivery or within 42 days of delivery or termination of pregnancy at the hospital. Data were collected prospectively in consecutive patients in a pro forma manner and entered into SPSS version 17 for Windows. RESULTS There was a total of 2,236 deliveries, of which 88 had severe maternal outcomes. Of the latter, 60 were maternal near-misses, while 28 suffered maternal death. The maternal near-miss:mortality ratio was found to be 2.14. The maternal mortality ratio here was 1,252 per 100,000. All the 88 women that had severe maternal outcomes lived at least 5 km from the hospital. The leading organ-system dysfunction in this study was cardiovascular, manifesting as shock and cardiac arrest, and respiratory, manifesting as gasping and cyanosis. Leading complications were severe hemorrhage, anemia, and hypertensive disorders. The pattern of complications was similar in both near-misses and maternal deaths, but cases of hypertensive disorders and exploratory laparotomy as an intervention for those with organ dysfunction were noted to be higher in near-miss cases, and differences were statistically significant. CONCLUSION It was concluded that despite numerous similarities in the characteristics of patients who had had maternal near-misses or died, our study points out that those who succumb to death are often <40 years of age, poorly educated, unemployed, usually present as unbooked emergencies from a distance >5 km and suffer maternal death within 24 hours of presentation.
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Affiliation(s)
- George O Ugwu
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Chukwuemeka A Iyoke
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Euzebus C Ezugwu
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Leonard O Ajah
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Hyacinth E Onah
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Benjamin C Ozumba
- Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Nsukka, Nigeria
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van den Broek N. Happy Mother's Day? Maternal and neonatal mortality and morbidity in low- and middle-income countries. Int Health 2019; 11:353-357. [PMID: 31529113 PMCID: PMC6748767 DOI: 10.1093/inthealth/ihz058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/03/2019] [Accepted: 07/12/2019] [Indexed: 11/24/2022] Open
Abstract
At least 800 women die each day during pregnancy or birth and more than 15 000 babies each day are stillborn or die in the first month of life. Almost all of these deaths occur in low- and middle-income countries. Many more women and babies are known to suffer morbidity as a result of pregnancy and childbirth. However, reliable estimates of the burden of physical, psychological and social morbidity and comorbidity during and after pregnancy are not available. Although there is no single intervention or ‘magic bullet’ that would reduce mortality and improve health, there are evidence-based care packages which are defined and agreed internationally. A functioning health system with care available and accessible for everyone at all times is required to ensure women and babies survive and thrive.
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Affiliation(s)
- Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Aminu M, van den Broek N. Stillbirth in low- and middle-income countries: addressing the 'silent epidemic'. Int Health 2019; 11:237-239. [PMID: 31081893 PMCID: PMC6635884 DOI: 10.1093/inthealth/ihz015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/25/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mamuda Aminu
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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Wiggins D, Hundley VA, Wilkins C, Bond C, Walton G. The effect of a birthplace decision support tool on women’s decision-making and information gathering behaviours during pregnancy: mybirthplace study protocol. BMJ Health Care Inform 2018; 25:1-6. [DOI: 10.14236/jhi.v25i1.945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 09/08/2017] [Accepted: 12/07/2017] [Indexed: 11/18/2022] Open
Abstract
BackgroundThe Maternity Review for England highlighted the need for more accessible information to support decisions. This study assesses the effect of a decision support tool (DST) on women’s decision-making regarding birthplace.MethodsA mixed method sequential exploratory design involving three phases and 169 women from a large UK maternity hospital. Phase one: A questionnaire survey pre and post-access to the DST examining knowledge level and stages of decision-making scale. Phase 2: Follow-up questionnaire at 28 weeks to enable the usefulness of Mybirthplace to be evaluated. Phase 3: Qualitative interviews with 10 purposely chosen women at 36 weeks gestation. Collection of data on actual birthplace.DiscussionThis study is the first to assess the effect of a DST in supporting women’s choice of place of birth.
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Oladapo OT, Adetoro OO, Ekele BA, Chama C, Etuk SJ, Aboyeji AP, Onah HE, Abasiattai AM, Adamu AN, Adegbola O, Adeniran AS, Aimakhu CO, Akinsanya O, Aliyu LD, Ande AB, Ashimi A, Bwala M, Fabamwo A, Geidam AD, Ikechebelu JI, Imaralu JO, Kuti O, Nwachukwu D, Omo‐Aghoja L, Tunau K, Tukur J, Umeora OUJ, Umezulike AC, Dada OA, Tunçalp Ӧ, Vogel JP, Gülmezoglu AM. When getting there is not enough: a nationwide cross-sectional study of 998 maternal deaths and 1451 near-misses in public tertiary hospitals in a low-income country. BJOG 2016; 123:928-38. [PMID: 25974281 PMCID: PMC5016783 DOI: 10.1111/1471-0528.13450] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the burden and causes of life-threatening maternal complications and the quality of emergency obstetric care in Nigerian public tertiary hospitals. DESIGN Nationwide cross-sectional study. SETTING Forty-two tertiary hospitals. POPULATION Women admitted for pregnancy, childbirth and puerperal complications. METHODS All cases of severe maternal outcome (SMO: maternal near-miss or maternal death) were prospectively identified using the WHO criteria over a 1-year period. MAIN OUTCOME MEASURES Incidence and causes of SMO, health service events, case fatality rate, and mortality index (% of maternal death/SMO). RESULTS Participating hospitals recorded 91 724 live births and 5910 stillbirths. A total of 2449 women had an SMO, including 1451 near-misses and 998 maternal deaths (2.7, 1.6 and 1.1% of live births, respectively). The majority (91.8%) of SMO cases were admitted in critical condition. Leading causes of SMO were pre-eclampsia/eclampsia (23.4%) and postpartum haemorrhage (14.4%). The overall mortality index for life-threatening conditions was 40.8%. For all SMOs, the median time between diagnosis and critical intervention was 60 minutes (IQR: 21-215 minutes) but in 21.9% of cases, it was over 4 hours. Late presentation (35.3%), lack of health insurance (17.5%) and non-availability of blood/blood products (12.7%) were the most frequent problems associated with deficiencies in care. CONCLUSIONS Improving the chances of maternal survival would not only require timely application of life-saving interventions but also their safe, efficient and equitable use. Maternal mortality reduction strategies in Nigeria should address the deficiencies identified in tertiary hospital care and prioritise the prevention of severe complications at lower levels of care. TWEETABLE ABSTRACT Of 998 maternal deaths and 1451 near-misses reported in a network of 42 Nigerian tertiary hospitals in 1 year.
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Affiliation(s)
- OT Oladapo
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
| | - OO Adetoro
- Department of Obstetrics and GynaecologyOlabisi Onabanjo University Teaching HospitalSagamuNigeria
| | - BA Ekele
- Department of Obstetrics and GynaecologyUniversity of Abuja Teaching HospitalGwagwaladaNigeria
| | - C Chama
- Department of Obstetrics and GynaecologyUniversity of Maiduguri Teaching HospitalMaiduguriNigeria
| | - SJ Etuk
- Department of Obstetrics and GynaecologyUniversity of Calabar Teaching HospitalCalabarNigeria
| | - AP Aboyeji
- Department of Obstetrics and GynaecologyUniversity of Ilorin Teaching HospitalIlorinNigeria
| | - HE Onah
- Department of Obstetrics and GynaecologyUniversity of Nigeria Teaching HospitalEnuguNigeria
| | - AM Abasiattai
- Department of Obstetrics and GynaecologyUniversity of Uyo Teaching HospitalUyoNigeria
| | - AN Adamu
- Department of Obstetrics and GynaecologyFederal Medical CentreBirnin‐KebbiNigeria
| | - O Adegbola
- Department of Obstetrics and GynaecologyLagos University Teaching HospitalIdi‐ArabaNigeria
| | - AS Adeniran
- Department of Obstetrics and GynaecologyUniversity of Ilorin Teaching HospitalIlorinNigeria
| | - CO Aimakhu
- Department of Obstetrics and GynaecologyUniversity College HospitalIbadanNigeria
| | - O Akinsanya
- Department of Obstetrics and GynaecologyFederal Medical CentreOwoNigeria
| | - LD Aliyu
- Department of Obstetrics and GynaecologyAbubakar Tafawa Balewa University Teaching HospitalBauchiNigeria
| | - AB Ande
- Department of Obstetrics and GynaecologyUniversity of Benin Teaching HospitalBenin‐CityNigeria
| | - A Ashimi
- Department of Obstetrics and GynaecologyFederal Medical CentreBirnin‐KuduNigeria
| | - M Bwala
- Department of Obstetrics and GynaecologyFederal Medical CentreNguruNigeria
| | - A Fabamwo
- Department of Obstetrics and GynaecologyLagos State University Teaching HospitalIkejaNigeria
| | - AD Geidam
- Department of Obstetrics and GynaecologyUniversity of Maiduguri Teaching HospitalMaiduguriNigeria
| | - JI Ikechebelu
- Department of Obstetrics and GynaecologyNnamdi Azikwe University Teaching HospitalNnewiNigeria
| | - JO Imaralu
- Department of Obstetrics and GynaecologyObafemi Awolowo University Teaching Hospital ComplexIle‐IfeNigeria
| | - O Kuti
- Department of Obstetrics and GynaecologyObafemi Awolowo University Teaching Hospital ComplexIle‐IfeNigeria
| | - D Nwachukwu
- Department of Obstetrics and GynaecologyFederal Medical CentreBidaNigeria
| | - L Omo‐Aghoja
- Department of Obstetrics and GynaecologyDelta State University Teaching HospitalAbrakaNigeria
| | - K Tunau
- Department of Obstetrics and GynaecologyUsmanu DanFodiyo University Teaching HospitalSokotoNigeria
| | - J Tukur
- Department of Obstetrics and GynaecologyAminu Kano University Teaching HospitalKanoNigeria
| | - OUJ Umeora
- Department of Obstetrics and GynaecologyFederal University Teaching HospitalAbakalikiNigeria
| | - AC Umezulike
- Department of Obstetrics and GynaecologyNational HospitalAbujaNigeria
| | - OA Dada
- Centre for Research in Reproductive HealthSagamuNigeria
| | - Ӧ Tunçalp
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
| | - JP Vogel
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
| | - AM Gülmezoglu
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)World Health OrganizationGenevaSwitzerland
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Making It Happen: Training health-care providers in emergency obstetric and newborn care. Best Pract Res Clin Obstet Gynaecol 2015; 29:1077-91. [DOI: 10.1016/j.bpobgyn.2015.03.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/23/2015] [Indexed: 11/22/2022]
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O'Donnell E, Utz B, Khonje D, van den Broek N. 'At the right time, in the right way, with the right resources': perceptions of the quality of care provided during childbirth in Malawi. BMC Pregnancy Childbirth 2014; 14:248. [PMID: 25069534 PMCID: PMC4133077 DOI: 10.1186/1471-2393-14-248] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 07/07/2014] [Indexed: 12/02/2022] Open
Abstract
Background Improving the quality of care women receive during childbirth is as important as ensuring increased availability of care and numbers of healthcare providers. To be able to improve quality of care, it is important to understand what quality means for mothers as well as providers of care. Methods 33 postnatal mothers and 10 healthcare providers from all 4 major hospitals in one district in Malawi were interviewed via 27 in-depth interviews and 2 focus group discussions. Data was transcribed and analysed using the thematic framework approach. Results Perceptions of quality of care differed substantially between care providers and postnatal mothers. For caregivers, characteristics of good quality care included availability of resources while for postnatal mothers positive relationships with their caregiver were important. Lack of autonomy and decision making power is a barrier to quality of care and it exists both at the level of the patient (mother) and at the level of her caregiver with healthcare providers unable to influence decisions made by more senior staff or management. Lack of autonomy was linked with the emerging themes of staff de-motivation, frustration, lack of empowerment to make change and resulting in a poor quality of care provided. Conclusions Creating a reciprocal understanding of what good quality care comprises and the barriers as well as promoters of this should be the starting point for improving the quality of maternity care. A renewed focus is needed on improving communication, strengthening patient rights and autonomy whilst simultaneously motivating and enabling healthcare workers to provide comprehensive and inclusive quality of care.
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Affiliation(s)
| | | | | | - Nynke van den Broek
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK.
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Dettrick Z, Firth S, Jimenez Soto E. Do strategies to improve quality of maternal and child health care in lower and middle income countries lead to improved outcomes? A review of the evidence. PLoS One 2013; 8:e83070. [PMID: 24349435 PMCID: PMC3857295 DOI: 10.1371/journal.pone.0083070] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 11/07/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Efforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship. METHODS We undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence. FINDINGS Methodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions. CONCLUSION Existing evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care.
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Affiliation(s)
- Zoe Dettrick
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
- * E-mail:
| | - Sonja Firth
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - Eliana Jimenez Soto
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
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Milner KM, Duke T, Bucens I. Reducing newborn mortality in the Asia-Pacific region: Quality hospital services and community-based care. J Paediatr Child Health 2013; 49:511-8. [PMID: 23713996 DOI: 10.1111/jpc.12249] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2013] [Indexed: 11/29/2022]
Abstract
Improving newborn health and survival is an essential part of progression toward Millennium Development Goal 4 in the World Health Organization Western Pacific and South East Asian regions. Both community and facility-based services are required. Strategies to improve the quality of care provided for newborns in health clinics and district- and referral-level hospitals have been relatively neglected in most countries in the region and in the published literature. Indirect historical evidence suggests that improving facility-based care will be an increasing priority for improving newborn survival in Asia and the Pacific as newborn mortality rates decrease and health systems contexts change. There are deficiencies in many aspects of newborn care, including immediate care and care for seriously ill newborns, which contribute substantially to regional newborn morbidity and mortality. We propose a practical quality improvement approach, based on models and standards of newborn care for primary-, district- and referral-level heath facilities and incorporated within existing maternal, newborn and child health programmes. There are examples where such approaches are being used effectively. There is a need to produce more nurses, community health workers and doctors with skills in care of the well and the sick newborn, and there are World Health Organization models of training to support this, including guidelines on emergency obstetric and newborn care and the Pocket Book of Hospital Care for Children. There are also simple data collection and analysis programmes that can assist in auditing outcomes, problem identification and health services planning. Finally, with increased survival rates there are gaps in follow-up care for newborns at high risk of long-term health and developmental impairments, and addressing this will be necessary to ensure optimal developmental and health outcomes for these children.
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Affiliation(s)
- Kate M Milner
- Centre for International Child Health, Department of Paediatrics, University of Melbourne, VIC 3052, Australia.
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Raj SS, Maine D, Sahoo PK, Manthri S, Chauhan K. Meeting the community halfway to reduce maternal deaths? Evidence from a community-based maternal death review in Uttar Pradesh, India. GLOBAL HEALTH: SCIENCE AND PRACTICE 2013; 1:84-96. [PMID: 25276519 PMCID: PMC4168560 DOI: 10.9745/ghsp-d-12-00049] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/21/2012] [Indexed: 11/15/2022]
Abstract
Even in the face of vigorous commitment to improving maternal health services in India, inadequate staffing, supplies, and equipment at health facilities, as well as transportation costs and delays in referral, appear to contribute to a substantial proportion of maternal deaths in a representative district in Uttar Pradesh. Background: Uttar Pradesh (UP) is the most populous state in India with the second highest reported maternal mortality ratio in the country. In an effort to analyze the reasons for maternal deaths and implement appropriate interventions, the Government of India introduced Maternal Death Review guidelines in 2010. Methods: We assessed causes of and factors leading to maternal deaths in Unnao District, UP, through 2 methods. First, we conducted a facility gap assessment in 15 of the 16 block-level and district health facilities to collect information on the performance of the facilities in terms of treating obstetric complications. Second, teams of trained physicians conducted community-based maternal death reviews (verbal autopsies) in a sample of maternal deaths occurring between June 1, 2009, and May 31, 2010. Results: Of the 248 maternal deaths that would be expected in this district in a year, we identified 153 (62%) through community workers and conducted verbal autopsies with families of 57 of them. Verbal autopsies indicated that 23% and 30% of these maternal deaths occurred at home and on the way to a health facility, respectively. Most of the women who died had been taken to at least 2 health facilities. The facility assessment revealed that only the district hospital met the recommended criteria for either basic or comprehensive emergency obstetric and neonatal care. Conclusions: Life-saving treatment of obstetric complications was not offered at the appropriate level of government facilities in a representative district in UP, and an inadequate referral system provided fatal delays. Expensive transportation costs to get pregnant women to a functioning medical facility also contributed to maternal death. The maternal death review, coupled with the facility gap assessment, is a useful tool to address the adequacy of emergency obstetric and neonatal care services to prevent further maternal deaths.
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Ameh C, Msuya S, Hofman J, Raven J, Mathai M, van den Broek N. Status of emergency obstetric care in six developing countries five years before the MDG targets for maternal and newborn health. PLoS One 2012; 7:e49938. [PMID: 23236357 PMCID: PMC3516515 DOI: 10.1371/journal.pone.0049938] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 10/18/2012] [Indexed: 11/25/2022] Open
Abstract
Background Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population. Methods and Findings A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%. Conclusions Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.
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Affiliation(s)
- Charles Ameh
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sia Msuya
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Jan Hofman
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Joanna Raven
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Matthews Mathai
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
| | - Nynke van den Broek
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Pyone T, Sorensen BL, Tellier S. Childbirth attendance strategies and their impact on maternal mortality and morbidity in low-income settings: a systematic review. Acta Obstet Gynecol Scand 2012; 91:1029-37. [PMID: 22583081 DOI: 10.1111/j.1600-0412.2012.01460.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review quantitative evidence of the effect on maternal health of different childbirth attendance strategies in low-income settings. DESIGN Systematic review. METHODS Studies using quantitative methods, referring to the period 1987-2011, written in English and reporting the impact of childbirth attendance strategies on maternal mortality or morbidity in low-income settings were included. Guidelines developed by the Cochrane collaboration and the Centre for Review and Dissemination, University of York were followed. The included articles were read and sorted by category of strategy that emerged from the reading. RESULTS The search criteria yielded 29 articles. The following three main categories of strategy emerged: (i) those primarily intended to improve quality of care; (ii) "centrifugal strategies," which sought to bring services to the women; and (iii) "centripetal strategies," which sought to bring the women to the services. Few of the studies had a design that provided strong evidence for the impact of the strategy concerned. CONCLUSIONS The evidence emerging from the studies was difficult to compare, because concepts were not defined in a consistent manner (such as "skilled birth attendance") and many studies examined the impact of a package of interventions without ferreting out the impact of individual components. Yet, some studies described individual aspects with great promise (such as cost, transport, outreach-friendly drugs or targeted training). There is a need for clearer conceptual frameworks, including some which permit assessment of packages of interventions.
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Affiliation(s)
- Thidar Pyone
- Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark.
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Landis Lewis Z, Mello-Thoms C, Gadabu OJ, Gillespie EM, Douglas GP, Crowley RS. The feasibility of automating audit and feedback for ART guideline adherence in Malawi. J Am Med Inform Assoc 2011; 18:868-74. [PMID: 21565857 PMCID: PMC3197989 DOI: 10.1136/amiajnl-2011-000097] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 04/19/2011] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi. MATERIALS AND METHODS We evaluated recommendations from Malawi's ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure's denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups. RESULTS We analyzed 423,831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi's ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled. DISCUSSION It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs' opportunities to reflect on their performance. CONCLUSION A moderate number of recommendations from Malawi's ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.
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Affiliation(s)
- Zach Landis Lewis
- Department of Biomedical Informatics, Center for Health Informatics for Underserved, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, USA.
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Bakker W, van den Akker T, Mwagomba B, Khukulu R, van Elteren M, van Roosmalen J. Health workers' perceptions of obstetric critical incident audit in Thyolo District, Malawi. Trop Med Int Health 2011; 16:1243-50. [PMID: 21767335 DOI: 10.1111/j.1365-3156.2011.02832.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess perceptions held by health workers in a Malawian district about obstetric critical incident audit. Insight into factors contributing to participation and endorsement may help to improve the audit process and reduce facility-based maternal and neonatal mortality and morbidity. METHODS This study involves semi-structured interviews with 25 district health workers, a focus group discussion and observation of audit sessions in health facilities in Thyolo District, Malawi, between August 2009 and January 2010. Data were analysed with maxqda 2010. RESULTS Findings were categorized into four major areas: (i) general knowledge of audit, (ii) participation in local audit and feedback sessions, (iii) the ability to reproduce the local audit cycle and (iv) effects and outcomes of audit and feedback. All health workers were familiar with the concept of audit and could reproduce the local cycle. Most health workers classified audit as an instructive and helpful tool to improve the quality of their work, provided that it is performed in a manner that enhances motivation and on-the-job learning. CONCLUSIONS Contradictory to recent reports from other African settings, which showed negative effects of audit on health workers' motivation, staff in this district considered audit and feedback valuable tools to enhance the quality of the care they provide. Audit has become part of the professional routine in the district, and its educational value was considered its most important appeal.
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Affiliation(s)
- Wouter Bakker
- Department of Medical Humanities, EMGO+ Institute, VU University Medical Centre, Amsterdam, The Netherlands
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Kongnyuy EJ, Hofman JJ, van den Broek N. Ensuring effective Essential Obstetric Care in resource poor settings. BJOG 2010; 116 Suppl 1:41-7. [PMID: 19740171 DOI: 10.1111/j.1471-0528.2009.02332.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although Emergency Obstetric Care (EOC) is globally accepted as a key strategy to improve maternal health and reduce maternal mortality, there is still a lot of debate surrounding its use--What is EOC? Is it evidence-based? How can we measure it? How can we improve access to EOC? This paper attempts to answer these questions. Although there are no randomized controlled trials, there is strong evidence from quasi-experimental, observational and ecological studies that EOC should be a critical component of any programme to reduce maternal mortality. This paper also identifies the barriers to accessing EOC and proposes strategies to overcome them which could contribute to achieving Millennium Development Goal 5.
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Affiliation(s)
- E J Kongnyuy
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, UK.
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van den Broek NR, Graham WJ. Quality of care for maternal and newborn health: the neglected agenda. BJOG 2010; 116 Suppl 1:18-21. [PMID: 19740165 DOI: 10.1111/j.1471-0528.2009.02333.x] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The quality of care received by mothers and babies in developing countries is often reported as poor. Yet efforts to address this contributory factor to maternal and newborn mortality have received less attention compared with barriers of access to care. The current heightened concern to achieve Millennium Development Goals 4 & 5 has illuminated the neglected quality agenda. Whilst there is no universally-accepted definition of "quality care", it is widely acknowledged to embrace multiple levels--from patient to health system, and multiple dimensions, including safety as well as efficiency. Quality care should thus lie at the core of all strategies for accelerating progress towards MDG4 &5. Interventions to measure and improve quality need themselves to be evidence-based. Two promising approaches are maternal and perinatal death reviews and criterion-based audit. These and other quality improvement tools have a crucial role to play in the implementation of effective maternal and newborn care.
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Affiliation(s)
- N R van den Broek
- Maternal and Newborn Health Unit, Liverpool School of Tropical Medicine, Liverpool, UK.
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Graham WJ. Criterion-based clinical audit in obstetrics: bridging the quality gap? Best Pract Res Clin Obstet Gynaecol 2009; 23:375-88. [PMID: 19299203 DOI: 10.1016/j.bpobgyn.2009.01.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Accepted: 01/26/2009] [Indexed: 11/17/2022]
Abstract
The Millennium Development Goal 5 - reducing maternal mortality by 75% - is unlikely to be met globally and for the majority of low-income countries. At this time of heightened concern to scale-up services for mothers and babies, it is crucial that not only shortfalls in the quantity of care - in terms of location and financial access - are addressed, but also the quality. Reductions in maternal and perinatal mortality in the immediate term depend in large part on the timely delivery of effective practices in the management of life-threatening complications. Such practices require a functioning health system - including skilled and motivated providers engaged with the women and communities whom they serve. Assuring the quality of this system, the services and the care that women receive requires many inputs, including effective and efficient monitoring mechanisms. The purpose of this article is to summarise the practical steps involved in applying one such mechanism, criterion-based clinical audit (CBCA), and to highlight recent lessons from its application in developing countries. Like all audit tools, the ultimate worth of CBCA relates to the action it stimulates in the health system and among providers.
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Affiliation(s)
- W J Graham
- Immpact, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK.
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