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Improving quality of care

for mothers and newborns

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WHO Quality of Care Vision | 16 April 2015

Quality of care matters


Due to focused efforts, facility-based deliveries is increasing globally
Higher proportion of avoidable maternal and perinatal morbidity
and mortality occur in facilities
Major roadblock: Quality of care
Coverage of essential interventions is not enough
WHO Multi-country study 2013
Provision of care as important as the experience of care
Barriers and facilitators to facility-based deliveries
Right to health
iERG: "quality of care is the route to equity and dignity for
women and children"
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WHO Quality of Care Vision | 16 April 2015

WHO vision
Preamble:
Efforts towards Universal Health Coverage
aim to provide all mothers and newborns with
access to the health care system
Every mother and newborn receives quality care
throughout pregnancy, childbirth and
the postnatal period

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WHO Quality of Care Vision | 16 April 2015

Investing in care around the time of childbirth:


a triple return on investment
Focus period:
Pregnancy care
Care around childbirth
for women and newborns
Care for the small and sick
newborns

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WHO Quality of Care Vision | 16 April 2015

for

Essential and additional care during the focus period


Antenatal care
Pre-clampsia/
eclampsia*: Magnesium
sulfate,
antihypertensive,
prompt delivery
Preterm labour:
Corticosteroids

Detection of nutritional deficiencies, Anemia, medical


infections, pre-eclampsia and medical disorders, infections:
Immediate treatment
conditions
Promotive and preventive care

Labour and
childbirth care

Labour monitoring and action


Childbirth care (incl. companion)
Newborn care at birth

Not breathing at birth:


Resuscitation

Suspected maternal
and newborn sepsis:
Early antibiotic
treatment

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Postnatal newborn
care
Postnatal maternal
care

WHO Quality of Care Vision | 16 April 2015

Labour difficulty:
augmentation, assisted
delivery or CS.
PPH: therapeutic
uterotonics, blood
transfusion, surgery

First week: exclusive BF, warmth, cord


care, hygiene
Routine monitoring
Counselling: BF, contraception,
nutrition

Preterm/LBW newborn:
Kangaroo Mother Care,
BF support

Definition of quality of care

The extent to which health services provided to individuals


and populations improve desired health outcomes.
In order to achieve this, health care needs to be

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WHO Quality of Care Vision | 16 April 2015

Characteristics of quality care


Safe delivering health care which minimizes risks and harm to service users,
including avoiding preventable injuries and reducing medical errors

Effective providing services based on scientific knowledge (WHO guidelines)

Timely reducing delays in providing/receiving health care


Efficient delivering health care in a manner which maximizes resource use and
avoids wastage

Equitable delivering health care which does not vary in quality because of personal
characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status;

People-centered providing care which takes into account the preferences and
aspirations of individual service users and the cultures of their communities

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WHO Quality of Care Vision | 16 April 2015

Health systems framework


Systems thinking for
health systems strengthening (2009)

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WHO Quality of Care Vision | 16 April 2015

Structure

Health system

Process

Quality
of Care

PROVISION OF CARE
1. Evidence based practices for
routine care and management
of complications
2. Actionable information
systems
3. Functional referral systems

EXPERIENCE OF CARE
4. Effective communication
5. Respect and dignity
6. Emotional support

7. Competent and motivated human resources

Outcome

8. Essential physical resources available

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Individual and facility-level outcomes


Coverage of key practices
People-centred outcomes
Health outcomes

WHO Quality of Care Vision | 16 April 2015

Priority evidence-based practices


With essential childbirth care including labour monitoring and action
and essential newborn care at birth and during the first week as the
foundation:
Management of pre-eclampsia, eclampsia and its complications;
Management of postpartum haemorrhage;
Management of difficult labour by enabling safe and appropriate use of
medical technologies during childbirth;
Newborn resuscitation;
Management of preterm labour, birth and appropriate care for preterm and
small babies;
Prevention and management of maternal and newborn infections.
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WHO Quality of Care Vision | 16 April 2015

QoC improvement strategy


Institutionalizing efforts under
government leadership

1. Establish leadership group

Adaptation and overcoming


barriers to implementation

2. Situation analysis / assessment

Responding to contextual
differences

4. Identify interventions & Set Goals

Selection of effective
intervention strategies
Roadmap for continuous and
sustainable quality improvement
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WHO Quality of Care Vision | 16 April 2015

3. Adapt service delivery standards

PLAN

5. Implementation
of interventions

ACT

DO

7. Refinement
of strategies

STUDY

6. Measurement of quality & outcomes

PDSA cycle
Identify interventions and set

PLAN

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Act

Plan

Study

Do

WHO Quality of Care Vision | 16 April 2015

goals

DO

Implement interventions &


strategies

STUDY

Assess process and


outcomes, analyze results

ACT

Refine strategies and scale


up best practices

Developmental work in pipeline


Quality of Care
Framework

Research
1. Establish leadership group
WHO Guidelines

Evidence-based intervention strategies to


improve QoC

3. Adapt service delivery standards


4. Identify interventions
PLAN

5. Implementation
of interventions

ACT

DO

7. Refinement
of strategies

STUDY

Measurement indicators and methods

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WHO Quality of Care Vision | 16 April 2015

6. Measurement of quality & outcomes

Capacity Strengthening

Service delivery standards

2. Situation analysis / assessment

Example: Draft standard for resuscitation


Quality statement:

Newborn resuscitation with bag and mask is effectively initiated in the newborn not breathing at
birth, within one minute after birth, if no spontaneously breathing after additional stimulation.
Quality measures/criteria:
Input
Evidence of local arrangements to ensure newborn resuscitation is initiated without delay in the
newborn not breathing spontaneously at birth
Availability of updated policy, procedure or guidelines consistent with WHO guidelines in
the delivery areas of maternity services
Proportion of health facilities with functional bags and masks (two neonatal mask sizes) in the
delivery areas of maternity services, at all times and in sufficient quantities, consistent with the
expected number of deliveries
Proportion of health facilities with health workers with skills in basic newborn resuscitation, as
demonstrated by positive pressure ventilation with bag and mask simulated on a manikin,
present at all times, in sufficient quantities and consistent with the expected number of deliveries
Output:

Proportion of all births that were resuscitated

Outcome: Early neonatal mortality in term babies without major congenital

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WHO Quality of Care Vision | 16 April 2015