Quality of maternal and newborn hospital care in Brazil: a quality improvement cycle using the WHO assessment and quality tool

Abstract

Background Increasing efforts towards quality improvement are necessary in low and middle-income countries to reduce maternal and perinatal mortality and morbidity, and to promote respectful care. In Brazil, perinatal health indicators are below targets in several States despite universal access to perinatal services and very high rates of institutional births, indicating poor quality of care (QoC) as a key issue to be addressed. However, research efforts to develop and test QoC improvement interventions are scarce. We assessed the effects of a 1-year comprehensive quality improvement cycle using a World Health Organization (WHO) assessment and quality tool on maternal and newborn care at hospital level and documented quality improvements obtained. Methods Uncontrolled, unblinded, pre-post study carried out in six maternity hospitals in Pernambuco, Brazil accounting for 29.128 live births in 2014. A standards-based, participatory approach based on a WHO quality assessment and improvement tool for maternal and neonatal care at hospital level. A national team of assessors supervised by international experts carried out baseline and final assessments. An action plan was developed and implemented to address key quality gaps emerging from the baseline assessment and from two supportive supervision visits. Results At baseline, hospitals presented a variety of quality gaps, the majority common to all participating centers. Gaps in case management of normal and complicated deliveries, and in respectful and holistic care were predominant, in both teaching/tertiary and secondary care hospitals. After one year, several improvements were observed, particularly in respectful care during labor and at delivery, in case management of normal labor and delivery, and in neonatal care. Conclusions A systematic participatory approach based on a WHO tool produced important quality improvements in a relatively short time and should be considered for use for large scale quality improvement programs in Brazil and other low and middle-income countries. Its comprehensive, peer-to-peer and action-oriented nature, its capability to document quality improvement over time and to build a quality improvement culture represent important comparative advantages over other quality improvement interventions.

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