Background: Maternal and neonatal mortality have declined in recent years. Few countries, however, will achieve the Millennium Development Goal for maternal mortality reduction and two million stillbirths and early neonatal deaths annually worldwide are related to intrapartum events. Assessments of maternal health programs are often limited to measuring service availability and utilization, such as through skilled birth attendance rates. Such indicators are not informative about the quality of care provided. Poor quality of care (QoC) may be implicated in low use of facility delivery and adverse outcomes, but there is limited availability of tools to rapidly and comprehensively measure the quality of the process of intrapartum and immediate postpartum care (QoPIIPC). The objective of this study was to identify the dimensions of QoPIIPC, and to develop observation-based measures representing these dimensions for use in evaluating facility-based L&D care in sub-Saharan Africa.Methods: A literature review was conducted of articles describing indicators to assess the quality of intrapartum/immediate postpartum care published between January 1990 and October 2013. Full-text review of articles meeting inclusion criteria documented characteristics including methods used to select indicators and data collection approaches. Indicators were evaluated for areas of emphasis and gaps. The findings of the literature review were used to develop an a priori model of the key dimensions of QoPIIPC. A Delphi process was conducted with a group of maternal and neonatal care (MNC) experts to revise the a priori model into a consensus model of QoPIIPC. Experts also rated items from a comprehensive delivery observation checklist, used in QoC surveys conducted in seven sub-Saharan African countries, for their importance in representing QoPIIPC. Combinations of highly-rated items were used to develop potential indices to measure QoPIIPC. The indices were evaluated for face, content, and criterion validity. Criterion validation used QoC survey data from Kenya, Madagascar, and Tanzania, including Zanzibar. A best performing comprehensive index of QoPIIPC was selected. To address concerns regarding the time required for observation-based QoC measurement of labor and delivery (L&D), items in the comprehensive QoPIIPC index were identified that could be assessed at and immediately after delivery. A ;;delivery-only” index composed of these indicators was evaluated for content and criterion validity, comparing performance to the comprehensive QoPIIPC index. Results: The literature review included 477 articles following application of inclusion and exclusion criteria. Analysis of these articles identified 16 single sentinel indicators of the quality of intrapartum/immediate postpartum care, 15 composite measures, and checklists of up to hundreds of items reflecting QoC. The review showed a lack of consensus in indicators for evaluating L&D care, particularly QoPIIPC, and identified gaps in available measures. Many sets of quality assessment indicators sets are long, making use difficult. Few indicators have been validated beyond expert opinion. Few measures are intended for use through clinical observation, the gold standard in quality assessment. The Delphi process with MNC experts identified five dimensions of QoPIIPC: technical quality, screening and monitoring, interpersonal care, infection prevention/control, and the avoidance of harmful/non-indicated interventions. Based on expert ratings of items representing QoPIIPC, 7 potential indices were developed. Using QoC survey data from Kenya, Madagascar, and Tanzania and applying validation benchmarks, a best-performing index was selected. This comprehensive QoPIIPC indes was composed of 20 MNC items covering 4 of the 5 dimensions of QoPIIPC – all but the avoidance of harmful/non-indicated interventions. This index was highly effective at discriminating between poorly and well-performed deliveries. Thirteen items in the comprehensive QoPIIPC index could be observed at or immediately after delivery. A delivery-only index of these items performed well on most validation benchmarks. However, the delivery-only index was weaker than the comprehensive index in representing all dimensions of QoPIIPC and in discriminating between good and poor performance cases. Conclusions: Attention is being paid worldwide to the role of QoC in achieving further reductions in maternal and newborn mortality. The literature review confirmed a need for validated, streamlined measures to facilitate observation-based QoPIIPC assessment, particularly in developing countries. Further evaluation of the usability and reliability of the QoPIIPC indices developed through this study is required. The findings suggest, however, that these indices may complement existing quality measures and enable rapid, ongoing observation-based assessment of L&D care in sub-Saharan Africa, facilitating targeted quality improvement. The delivery-only index may particularly support expansion of quality measurement in settings where supervisory resources are limited.
【 预 览 】
Development and Evaluation of Measures of the Quality of Facility-based Labor and Delivery Care in sub-Saharan Africa