Quality of care for pregnant women and newborns—the <scp>WHO</scp> vision

Abstract

In 2015, as we review progress towards Millennium Development Goals (MDGs), despite significant progress in reduction of mortality, we still have unacceptably high numbers of maternal and newborn deaths globally. Efforts over the past decade to reduce adverse outcomes for pregnant women and newborns have been directed at increasing skilled birth attendance.1, 2 This has resulted in higher rates of births in health facilities in all regions.3 The proportion of deliveries reportedly attended by skilled health personnel in developing countries rose from 56% in 1990 to 68% in 2012.4 With increasing utilisation of health services, a higher proportion of avoidable maternal and perinatal mortality and morbidity have moved to health facilities. In this context, poor quality of care (QoC) in many facilities becomes a paramount roadblock in our quest to end preventable mortality and morbidity. QoC during childbirth in health facilities reflects the available physical infrastructure, supplies, management, and human resources with the knowledge, skills and capacity to deal with pregnancy and childbirth—normal physiological, social and cultural processes, but prone to complications that may require prompt life-saving interventions. Research shows that it is necessary to go beyond maximising coverage of essential interventions to accelerate reductions in maternal and perinatal mortality and severe morbidity.5 Moreover, there is a complex interplay of experiences of mistreatment and lack of support that impact women's childbirth experiences and outcomes.6 Moving beyond 2015, the World Health Organization (WHO) envisions a world where ‘every pregnant woman and newborn receives quality care throughout pregnancy, childbirth and the postnatal period.’ This vision is in alignment with two complementary global action agendas conceptualised by WHO and partners in 2013–2014—'Strategies toward Ending Preventable Maternal Mortality (EPMM)' and ‘Every Newborn Action Plan (ENAP)’.7, 8 It is articulated at a critical time when the global community is developing the new Global Strategy for Women's, Children's and Adolescents' Health (2016–2030) for the post-2015 Sustainable Development Goal era.9 Although indirect causes of maternal death are increasing (27.5% of maternal deaths), globally, over 70% of maternal deaths occur as a result of complications of pregnancy and childbirth such as haemorrhage, hypertensive disorders, sepsis and abortion.10 Complications of preterm birth, birth asphyxia, intrapartum-related neonatal death and neonatal infections together account for more than 85% of newborn mortality.11 Therefore, the time of childbirth and the period immediately after birth are particularly critical for maternal, fetal and neonatal survival and well-being. Effective care to prevent and manage complications during this critical period is likely to have a significant impact on reducing maternal deaths, stillbirths and early neonatal deaths—a triple return on investment.12 Within this critical period, quality of care improvement efforts would target essential maternal and newborn care and additional care for management of complications that could achieve the highest impact on maternal, fetal and newborn survival and well-being. Based on the current evidence on burden and impact, the following specific thematic areas have been identified as high priority for this vision:10-12 To end preventable maternal and newborn morbidity and mortality, every pregnant woman and newborn need skilled care at birth with evidence-based practices delivered in a humane, supportive environment. Good quality of care requires appropriate use of effective clinical and non-clinical interventions, strengthened health infrastructure and optimum skills and attitude of health providers, resulting in improved health outcomes and positive experience of women and providers. Moreover, quality of care is considered a key component of the right to health, and the route to equity and dignity for women and children.13 So, what is quality of care? To underpin this vision, we need a common understanding of what it means. This WHO vision defines quality of care as ‘the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care needs to be safe, effective, timely, efficient, equitable, and people-centred.’14, 15 Operational definitions for the characteristics of quality of care are defined in Box 1. Quality of care is a multi-dimensional concept. Therefore, a framework with important domains of measurement and pathways to achieve the desired health outcomes is required to identify the action points to improve the quality of care. Since the Donabedian model of quality of care for health facilities was proposed in 1988, WHO and others have developed strategic thinking to operationalise key characteristics of QoC, using different elements from the provision of care as well as the