A series of MCHIP health facility surveys on quality of care (QoC) focus on the frequency and quality of interventions that address the direct causes of maternal and newborn deaths, and act as key sources of information for policymakers and other stakeholders in country. Good information on the background, study objectives, and methodology of these surveys can be found in this document.
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Quality of Care Tools:
- Health worker line listing: Produces a list of all health workers who provide services to mothers and newborns at the facility where observations will occur. Captures medical qualifications of the staff and assigns individual code for each health worker for use in the survey.
- Facility inventory: Reporting of infrastructure conditions and verification of availability and storage conditions of medications, supplies and equipment. Includes a short record review to capture the number of ANC consultations and deliveries at each facility for the last year, based on the health management information system (HMIS) tools (e.g., ANC register).
- Clinical practice observation of ANC and labor and delivery: Structured clinical observation checklists for observation of antenatal care consultations and labor and delivery (vaginal deliveries only) at the facilities. The content of the checklists was developed based on World Health Organization (WHO) guidelines and includes: screening for PE/E in ANC; management of PE/E and PPH in L&D; and other interventions in L&D—routine and correct use of the partograph, routine and correct use of AMTSL, infection prevention behaviors, provider-client interaction/communication, immediate essential newborn care and newborn resuscitation.
- Health worker interview and knowledge test: A series of questions to capture training and experience of the health worker and then test their knowledge of how to identify, manage and treat common MNH complications. Includes a simulated resuscitation with a newborn model to assess newborn resuscitation skills.
More information on these reports—from Kenya, Tanzania, Ethiopia, Madagascar, Zanzibar, Rwanda and Mozambique—is below:
- The brief Quality of Antenatal and Delivery Care Services in Six Countries in Sub-Saharan Africa presents a summary of study findings from six of the seven countries surveyed: Ethiopia, Kenya, Madagascar, Mozambique, Rwanda, and Tanzania (including Zanzibar). The seventh country, Zimbabwe, is not included here.
- The Kenya QoC survey—entitled Quality of Care for Prevention and Management of Common Maternal and Newborn Complications: Findings from a National Health Facility Survey in Kenya—was fielded as part of ICF Macro’s 2010 Kenya Service Provision Assessment (KSPA) in all eight provinces of the country in a representative sample of 409 health facilities. The primary areas assessed were: quality of routine antenatal care (ANC); quality of routine labor and delivery (L&D) care; infection control; client-provider communication; management of common complications at the time of delivery, including postpartum hemorrhage, pre-eclampsia/eclampsia (PE/E) and birth asphyxia; essential newborn care; harmful delivery practices; and facility readiness to provide quality care with respect to availability of supplies, equipment and infrastructure and health worker knowledge. The survey reveals the results of observations of 1,409 ANC consults and 626 deliveries, and interviews with 234 selected health workers across these facilities.
- The Tanzania reports—on labor and delivery, and antenatal care—highlight areas of relative strength as well as significant gaps in the provision of maternal and newborn care. The reports, entitled Quality of Care for Prevention and Management of Common Maternal and Newborn Complications: A study of 12 regions in Tanzania and Quality of Maternal and Newborn Health Services in Tanzania: A survey of the quality of maternal and newborn health in 12 regions of Tanzania, identified specific recommendations for changes in training and service delivery to improve maternal and newborn health outcomes, which will help guide policy and service delivery decisions of the Ministry of Health and Social Welfare and other key stakeholders in Tanzania. A followup survey was done in 2012 and four briefs summarize the results of the survey: on essential newborn care; pre-eclampsia/eclampsia; postpartum hemorrhage; and focused antenatal care.
- A report from Ethiopia—entitled Quality of Care for Prevention and Management of Common Maternal and Newborn Complications: A Study of Ethiopia’s Hospitals—reveals the results of examining the QoC of maternal and newborn health services during antenatal and delivery care in Ethiopia. The survey was fielded in the 19 Ethiopian hospitals with the heaviest volume of deliveries with a primary objective of determining the frequency and quality of interventions that address the direct causes of maternal and neonatal deaths, and to guide the need for and content of QoC improvement activities for maternal and newborn care at hospitals.
- A health facility survey from Madagascar examines the QoC of maternal and newborn health in the country, complementing and extending previous efforts at assessing the quality of maternal and newborn care in sub-Saharan Africa. The survey was designed with a particular focus on observations of providers during antenatal care and labor and delivery to assess the use of lifesaving interventions to prevent or manage common complications, and is part of a larger multi-country study. Available in both English and French, the report—entitled Quality of Care of the Prevention and Management of Common Maternal and Newborn Complications in Health Facilities in Madagascar—presents and discusses detailed findings related to antenatal care, infection prevention, normal labor and delivery, pre-eclampsia/eclampsia, obstructed/prolonged labor, postpartum hemorrhage, and newborn resuscitation. Cross-cutting findings and discussion are also presented, and recommendations are made for policy, facility readiness, and specific service components.
- The MAISHA Quality of Maternal and Newborn Health Services study in Zanzibar, conducted in November–December 2010, was an observational study conducted in nine health facilities in Pemba and Unguja. Entitled Quality of Maternal and Newborn Health Services in Zanzibar, 2010: Findings from Selected Health Facilities in Unguja and Pemba, the aim of the study was to provide strong information on the quality of maternal and newborn health care in these facilities, as an indication of current practice in maternal and newborn care in Zanzibar. The results serve as a baseline for the MAISHA program and as an important source of information on quality of maternal and newborn care for policymakers and stakeholders in Zanzibar.
- The QoC report from Rwanda, entitled Quality of Care for Prevention and Management of Common Maternal and Newborn Complications: Findings from a National Health Facility Survey in Rwanda, was conducted in 72 health facilities, with observation of close to 300 deliveries and 300 ANC consultations. Recommendations to improve the quality of maternal and newborn health services in Rwanda have been made based on the survey findings. The results will also be used to guide the Maternal and Child Health unit of the Rwanda Ministry of Health in strengthening their programs and policies to improve the quality of antenatal care and labor and delivery services, and will serve as baseline estimates in the evaluation of quality improvement activities.
- The QoC report from Mozambique, entitled Quality and Humanization of Care Assessment: A Study of the Quality of Maternal and Newborn Care Delivered in Mozambique’s Model Maternities summarizes the findings on ANC and L&D care from observations of 525 deliveries and 303 ANC consults in 46 facilities (17 facilities currently in the Ministry of Health’s Model Maternities Initiative and 29 in the future expansion plans for the initiative). The preliminary report was presented to the Ministry of Health within weeks of finalizing data collection in 2011 and implementation of key recommendations was fed into work planning for MCHIP support of expansion of the initiative. This included improvements in: supervision by MCHIP support for provincial level nurse supervisors; infrastructure in key maternities to increase privacy; screening for pre-eclampsia through provision of blood pressure cuffs in ANC clinics; preparation for emergency care through enforcement of policies to have birth kits prepared and nearby; and support for better use of partographs; as well as introduction of the Helping Babies Breathe system for newborn resuscitation.
Labor and Delivery Quality of Care Short Observational Index:
A validated tool for measuring the quality of routine intrapartum and immediate postpartum care was also developed using the QoC Survey data and tools. This tool, an observational checklist, comes in two versions: a comprehensive index for assessing actions across all the stages of labor and delivery care; and a “delivery-only” index that focuses on the time of delivery and the first hour after birth. A user guideprovides both versions of the observational checklist as well as information on why and how the tool should be used. Orientation resources have also been developed to support new users in preparing to use the observational checklist(s).
- Session 1: Short L&D index and orientation overview
- Session 2: Structured clinical observation
- Session 3: Collecting high-quality observation data
- Session 4: Understanding the short L&D index
- Session 7: Inter-rater reliability exercise
- Session 8: Roles & responsibilities of observers
- Session 12: Planning to use the short L&D index
Handouts and worksheets:
- Data quality activity (Session 3)
- Data quality handout (Session 3)
- Facilitator’s worksheet – inter-rater reliability exercise (Session 7)
- Planning for use worksheet (Session 12)